Creative Activities for Group Therapy [2 ed.] 2022041168, 2022041169, 9781032171463, 9781032171470, 9781003251989

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Creative Activities for Group Therapy

The second edition of Creative Activities for Group Therapy focuses on evidence-based alternatives for verbal expression in group therapy, which provide group leaders with innovative inspirational tools, techniques, and intervention strategies to address dilemmas and difficult situations, and help encourage members’ self-exploration and self-disclosure. Newly organized into three categories, the book covers group basics and fundamentals, categories for activities, and a new section on diverse settings, conditions, and applications. The first section outlines the use of activities, benefits to groups, and tips for effective and safe use of creative activities. Section two covers a range of creative activities for leaders to implement, such as art therapies, movement therapies, and writing therapy, and includes new activities for virtual sessions. The new section then addresses activities for diverse settings such as groups in hospitals and prisons, various medical conditions and psychological states, and inclusive applications that minimize group conflict and promote emotional expression. This new edition provides mental health professionals and students, including therapists, counselors, and clinical social workers, with a wide array of methods for enriching their therapy groups, and tools for implementing these activities. Nina W. Brown is a professor and eminent scholar at Old Dominion University in Norfolk, VA. She received her doctorate from the College of William and Mary and is the author of over 40 published books.

Creative Activities for Group Therapy

Second edition

Nina W. Brown

© Getty Images Second edition published 2023 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 Nina W. Brown The right of Nina W. Brown to be identified as author of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2013 Library of Congress Cataloging-in-Publication Data Names: Brown, Nina W., author. Title: Creative activities for group therapy / by Nina W. Brown. Description: Second edition. | New York, NY : Routledge, 2023. | Includes bibliographical references and index. | Identifiers: LCCN 2022041168 (print) | LCCN 2022041169 (ebook) | ISBN 9781032171463 (hbk) | ISBN 9781032171470 (pbk) | ISBN 9781003251989 (ebk) Subjects: LCSH: Group psychotherapy. | Group counseling. | Psychotherapist and patient. Classification: LCC RC488 .B738 2023 (print) | LCC RC488 (ebook) | DDC 616.89/152--dc23/eng/20220912 LC record available at https://lccn.loc.gov/2022041168 LC ebook record available at https://lccn.loc.gov/2022041169 ISBN: 978-1-032-17146-3 (hbk) ISBN: 978-1-032-17147-0 (pbk) ISBN: 978-1-003-25198-9 (ebk) DOI: 10.4324/9781003251989 Typeset in Baskerville by Taylor & Francis Books

This second edition is dedicated to Marsha Block who as the former CEO of the American Group Psychotherapy Association used her creative talents to sustain a viable and valuable organization. I want to especially thank her for her support and encouragement during the successful preparation of the petition to have group therapy recognized as a specialty by the American Psychological Association.

Contents

Preface Acknowledgments 1 Introduction

viii x 1

2 Procedures and Process for Use of Creative Activities

22

3 Group Leader Facilitation Attributes and Skills

44

4 Art Activities: Drawing and Collage

67

5 Writing Activities: Essays, Lists, Journals, Poetry, and Cinquains

92

6 Physical Movement: Dance, Physical Exercise, Performance

119

7 Imagery, Mindfulness, and Music

138

8 Stories, Memories, Photos, Visual Journals, Flats, and Books

161

9 Creative Activities for Some Restrictive and Virtual Settings

177

10 Creative Activities for Diverse Conditions

200

11 Applications for Fostering Group Dynamics

225

Index

248

Preface

The second edition for creative activities presents evidence-based activities for group therapy that include a variety of inspirational activities for use in a variety of settings and conditions. The activities and other book material are designed to do the following: 1 2 3 4 5

Present evidence-based categories of activities that are non-threatening, easy to implement, and that can be helpful to promote group process. Describe strategies that provide a means to uncover nonconscious and unconscious material. Clarify members’ associations and unfinished business that can lead to understanding, growth, and healing. Promote group members’ self-exploration, self-disclosure, and their understanding of underlying issues and concerns. Present activities to promote positive aspects of self, solve individual and group problems and dilemmas, and illustrate how to build meaningful and satisfying relationships among group members.

This edition presents a variety of activities that are suitable for the variety of group members encountered in most group therapy. In addition, these can be implemented by most group leaders as no specialized training is needed by group leaders to adequately implement the activities. The activities presented intended that group members interpret their own products and not the leader or other group members, which can deepen the group experience and promote insight for the particular group member. Activities can be immediately implemented, as extensive directions and guidelines are described including suggestions for guiding the members to understand their own unique personal products. The book focuses on alternatives for verbal expression in group therapy, encouraging members’ self-exploration and self-disclosure, strategies for working around resistance, and defenses to access and express nonconscious and unconscious material, and can facilitate members’ self-affirmations. The creative activities can stimulate expressions of thoughts, ideas, feelings, and

Preface

ix

associations, and do so in a non-threatening way. Additional applications are provided for group dilemmas, especially for those where the usual strategies are not effective. An unusual feature is the variety of different activities that group leaders can choose from to fit their talents as well as the group’s needs. The creative and inspirational activities provide the following advantages:








Simultaneous self-exploration by group members where each can participate at the same time. Prevent common difficult member behaviors, such as monopolizing, story-telling, and prolonged silence by a member or members. Present a means whereby low verbal group members can express their experiencing without having to grope for words. Allow for safer expression of difficult, and/or unacceptable feelings, thoughts, associations, and the like. The presented activities and procedures are guides for explorations that facilitate linking, associations with unfinished business and unresolved issues, and insight. There are also activities that can assist group members to capitalize on their strengths to make changes, grow, develop, and to heal. The group leader does not need specialized training to implement the activities in the book.

Finally, the new edition presents additional new activities and new categories of activities, a new section on strategies for creative activities for virtual sessions, and activities helpful to the group leader to promote group therapeutic factors such as cohesion, universality, and interpersonal learning; solve group difficulties such as conflict, and to build self-adequacy.

Acknowledgments

This book could not have been written without the learning I accumulated throughout the years about group therapy, leading groups, how group members learn and heal, and other clinical aspects that guide group leaders. Attending conferences such as the Mid-Atlantic Group Psychotherapy Society and the American Group Psychotherapy Association allowed me to experience first-hand the myriad of creative activities that can contribute to group therapy’s success. I was introduced to the wide variety of such activities, experienced their benefits, and observed the impact of these on the other participants. Learning by doing was extremely effective and that is what I hope to accomplish for others with this book. Many thanks to the clinicians whose presentations I attended over the years. I wish to also acknowledge the contributions of the editors and editorial staff at Routledge who guided me through the process for publishing. Sincere appreciations are extended to all involved editors, staff, proofreaders, technicians, and others involved in publishing. While I may not know you personally, your contributions are appreciated.

Chapter 1

Introduction

Welcome to the second edition of Creative Activities in Group Therapy. This edition extends the presentation of creative activities with additional material for their effective use. It is important that activities are used in ways that will benefit individual group members as well as the group as a whole, as it is important for group leaders to facilitate the group’s development as well as that for group members. It is also important and essential that group leaders select and use creative activities with sensitivity for members’ emotional states, their unique cultural and diversity factors, and with a deep understanding of the group as a whole’s needs and desires as these foster the group’s progress. The activities contained in this book, while easy to implement, also have other helpful aspects such as ease of implementation, guides to deepen and expand the experiences, assistance to members for self-exploration, and are helpful enhancements for some group processes. The activities can be more safely used to benefit members and the group because all are presented as requiring group members’ informed consent to their participation. Group leaders are cautioned to let group members decide and agree to participate and are the deciders of the level and extent of their disclosures and interpretations. All activities list materials needed and the steps for implementation, which helps the leader to better know if the activity is suitable for members’ abilities and the group’s development. Guidelines present procedures to introduce the activities, assist members with their productions, and to lead the leader to expand and enhance members’ reporting of the outcomes for the activity. Guidelines are also provided for group leaders to help foster the emergence of helpful group therapeutic factors, manage some member behaviors that are troubling or difficult in the group setting, and address commonly appearing group dilemmas. The following is an example for a creative activity, a cinquain that can promote deeper understanding.

DOI: 10.4324/9781003251989-1

2 Introduction

Creative activities Alternative paths to understanding Inspiring, challenging, soothing, stimulating, exciting, expanding, enchanting, pleasurable Communications from the internal self New meanings Presented is a cinquain used as a way to expand the image and understanding for creative activities. It begins with a title of two words, the second line describes what it is with four words, the third line provides eight adjectives about it, the fourth line provides the understanding of what it does in four words, and the last line with two words renames it. The structure of a cinquain starts with either one or two words, doubles for the description, redoubles the number of words for the adjectives, reduces back to the double, and then back to the beginning of one or two words. This is an example of a creative activity.

Organization of the Book The chapters are organized to first present the background that includes the benefits and advantages for using creative activities, the principles for experiential learning, some guiding theories, how these activities can assist the group leader with difficulties that arise in the group, an overview of the categories for the activities, the relevant ethics for using creative activities, and some basic group leader preparation. Central to the presentation and use of these activities is the focus that these are alternatives for verbal expressions in group therapy, they encourage members’ self-exploration and self-disclosure, they can assist to work around resistance and defenses to help access and express nonconscious and unconscious, and can provide members with some self-affirmations. These activities can stimulate expressions of thoughts, ideas, feelings and associations in a non-threatening way. Also, additional applications are provided for group dilemmas, especially for those where the usual strategies are not effective. A defining feature for the book is the variety of different activities where group leaders can select those that best fit their group and do not require additional training for the group leader although some specific training is encouraged.

Benefits and Advantages for Group Members Group leaders will find that using creative activities has many benefits and advantages for the members and for the group. Among the major benefits and advantages are the following:

Introduction









3

Provide simultaneous self-exploration for all group members at the same time. Can prevent common difficult member behaviors such as monopolizing, story-telling and prolonged silence. Offer a means and the opportunity for low-verbal group members to express their experiencing without having to grope for words. The expression of difficult and/or unacceptable feelings, thoughts, and associations are more safely facilitated. The activities and facilitation procedures are guides for the kind of explorations and assist group members to link and make associations with unfinished business and unresolved issues, and can provide insight. The group leader does not need specialized training to implement the activities presented although some training for leaders is encouraged.

Rationale Definitions for the term creative use words and phrases such as, to bring into being, original, new, and novel, and this forms the basis for the activities described in this book. Creative activities are defined here as stimuli that can have the following effects and outcomes for both individual group members and for the group as a whole. These stimuli are taken from artistic, performing, and other such endeavors as well as the vast world of crafts. Effects and outcomes include:
















Inspiring and challenging the creator Providing a focus for internal and external chaos, and screening out distractions Distracting from unproductive worrying Expressing complicated thoughts, feelings, and ideas Clarifying perceptions of situations, people, and the like Helping to bring the obvious into focus, and highlighting important aspects A solace when confused, upset, or indecisive Helping sort through complex and conflicting values Can be centering and grounding New meanings can emerge Abstracting essentials from surrounding confusion, barrages, etc. Simplifying complexity Can address several levels and planes simultaneously Providing new ways to perceive and relate Reconnecting parts of the self to become balanced and rounded

Creative activities tap both the internal and external experiencing when used in a group setting. The internal experiencing is made visible through the product of the creative activity, and the external experiencing occurs with the communication about the product and what occurred for the person in

4 Introduction

the production phase, and in the reactions and feedback from other group members and the leader. This process can enhance growth and development, stimulate self-exploration as new awareness emerges, can assist to soothe and calm, and deepens and broadens thoughts and feelings. Both the members and the group as a whole can benefit with use of creative activities. Benefits for the Group The benefits for use of creative activities can also enhance the functioning and progress of the group and assist the group leader to capitalize on the resources that the group can provide. Leading a group is a delicate balancing act of tasks, dynamic group and individual factors, and the group leader’s expertise and skill are fundamental to maintaining this balance. The group’s goal is important as a guide, members’ needs must be identified, and attempts made to meet some or all of them, the group as a whole attended to, and many other factors and tasks needed for success also play roles. The central and critical figure and component is the group leader, and their knowledge, skills, and level of personal development are vital to the members’ growth, development, and healing. However, no matter how competent and well-prepared the group leader is, there can be group situations that present challenges that are not easily addressed, defy conventional interventions, and call for a different approach. This book was developed to present one such different approach, the use of creative activities applied to group dilemmas and personal situations. These activities are conceptualized as being non-threatening means to access material contributing to the dilemma or situation, expressing difficult feelings, and allowing the individual members to better understand their personal responses that are contributing to the dilemmas or situation. Some examples include the following:






Stuck or mired where the discussion becomes circular, no problem-solving or insight occurs, members are exasperated but cannot seem to change the pattern, and therapeutic work is not being accomplished. Conflict has emerged in the group and is being ignored, suppressed, or denied. Or, the members fear conflict so much that they will go to extraordinary means to keep it under wraps, and pretend that they are harmonious. The group seems overly or under energized. When overly energized, they skip from topic to topic, none of which are adding to the work of the group, a lot of squirming and other nonverbal communication of discomfort occurs, but interventions do not seem to help them concentrate or focus. The under-energized group seems depressed or dead, but they resist exploration of their feelings.

Introduction








5

Many or even most group members either cannot or do not express their feelings, or express them in inappropriate ways. Feelings seem to be considered as dangerous and members avoid them. Members are exhibiting resistance and defensiveness well beyond what is usually expected in the group. They are not making meaningful connections with each other, and are avoiding attempts to promote interactions and involvement. Members are extremely tentative and cautious in revealing their selves to the point where they do not disclose anything of importance. While safety and trust need to be established before meaningful connections and disclosures can appear, this wariness has continued to the point where the therapeutic work is thwarted.

Group leaders encountering these dilemmas and situations will intervene as best they can, given their understanding of the group and its needs. However, there are groups where the usual conventions do not work. The material presented in this book is intended to give group leaders other tools, techniques, intervention strategies, and the like to not only address dilemmas and situations, but also to present them with alternatives designed to stimulate exploration and expansion of members’ understanding of their personal issues. A Rationale for Using Creative Activities for Group Dilemmas It would be the rare group leader who has not encountered one or more group dilemmas where the group became mired, tense, unproductive, little therapeutic work was accomplished, and this lasted more than one session. While frustrating for the group leader, these situations can be even more frustrating for group members who probably lack the developed inner resources for coping that the leader may have, leading to a very uncomfortable group situation for all. Adding to the frustration for the group leader is when all interventions tried do not move the group from the uncomfortable place. The leader’s analysis does not seem to be effective to produce understanding, or for suggested interventions, no matter how experienced or competent the leader is. While these group situations are few and far between, they can occur without warning. These group dilemmas differ from those presented by a difficult group member. Brown (2006) and Alonso and Rutan (1993, 1996) describe some group dilemmas that can result from the presence of members with unidentified problems and concerns such as, the member with a Narcissistic Personality Disorder or with a Destructive Narcissistic Pattern, a member with a Borderline condition, or a quiet explosive member. They propose that the difficulties and dilemmas in these instances, result from the group’s effort to manage and contain these members, the members’ unconscious sensing of danger and possible destruction for their selves, and their attempts to control their intense emotions

6 Introduction

that were unconsciously aroused by these members. The leader and members are working in the dark, but nothing constructive can happen until the difficult member is identified and appropriate actions are taken. These difficult group members present their own variations for group dilemmas, but this is not what is meant for this book. Suffice it to say that group leaders encountering these dilemmas look for ways to understand the indirect communication so as to select appropriate interventions. The group members do not have the ability to be clearer in communication because they do not know what it is they want to communicate, can be fearful of consequences for what may emerge, are trying to understand and communicate but are ineffective, and are frustrated at the lack of clarity and understanding from self, other members, and the leader. This book proposes that the described creative activities can assist the group leader to address the group dilemmas, and provide relevant material for group members’ self-exploration. These activities, although group-centered and focused, can be personal for each member, bypass defenses, reveal unconscious and hidden material in ways that can be perceived by them as less threatening and dangerous, be encouraging for expression of difficult and/or complex ideas, thoughts, and feelings, and even may provide guidance to solutions for some members. At the very least, these creative activities can provide a release of tension so that group members can think more clearly, be more responsive, and be more willing to engage in self-exploration. Both the group and members can benefit.

Principles of Experiential Learning These principles are drawn from the concept of experiential learning proposed by Kurt Lewin (1944) whereby learning is enhanced through group participation. Three basic principles are used here: the contributions of the group environment, active participation, and group membership.





The social and supportive environment provided by the group promotes intrapersonal and interpersonal learning. This environment encourages experimentation with new ways of behaving and relating by providing safety and trust; can open new pathways of understanding oneself and others; constructive feedback can be given and received, and self-perceptions are more likely to be changed, or become more open to change. Learning is facilitated by active participation. When group members are actively involved their different learning styles can be accommodated; the learner can choose to focus on what they consider to be personally important; more than one system can be tapped at one time – physical, cognitive, emotional, creative, inspirational, and difficult material can be more easily accepted when personally discovered thereby reducing resistance and defensiveness.

Introduction




7

Accepting membership in the group encourages behavioral and attitudinal change. Acceptance is facilitated by presenting oneself in a nonthreatening way and receiving positive responses and feedback from other group members.

Additional fundamental assumptions are that the group activities foster the emergence of many group-curative factors, promote self-disclosure and member interactions, offer opportunities for members to discover unknown or forgotten parts of self, and that these can highlight important material for members’ exploration. In addition, the activities can strengthen connections among group members, reduce resistance and defensiveness, and teach new ways of understanding, behaving, and relating.

Theoretical Perspectives The book does not follow a particular theoretical perspective, and the activities reflect the atheoretical approach. However, there are four main theories that guided the development and selection of the activities: Behavioral, Cognitive, Dialectical Behavioral Therapy, and Object-Relations/Self-Psychology. Guidance from behavioral therapy includes the use of imagery (Lazarus, 1989), behavioral rehearsal, progressive relaxation, and self-modification (Corey, 2009). The assumptions from Behavioral therapy are that clients are expected to assume an active role, that insight is not necessary for behavioral changes, and that interventions are best targeted to specific behaviors tailored for the individual. Cognitive theories of Beck (1995), Ellis (1997), and Meichenbaum (1977) provide the perspective that many psychological difficulties stem from faulty or irrational thinking, incorrect inferences or misinformation, and an inability to distinguish between fantasy and reality. The activities in the book address cognitive distortions such as, catastrophizing, inferring the whole from a detail, overgeneralization, magnification and minimization, personalization, labeling and mislabeling, and dichotomous thinking. Dialectical Behavioral Therapy (DBT) (Linenhan, 1993) contributes the integration of mindfulness into therapy, existential factors, and strategies for emotional regulation and control. Although not used in a systematic way as in DBT, the activities capitalize on these strategies and adapt them for use in the group setting. Object-relations and self-psychology theories contribute to the understanding of what can emerge during the creative activity as well as for the outcomes. These theories are more geared to the group leader’s understanding, and how to guide members’ exploration and enhancement of their products. Object-Relations theories (OR), such as those of Klein (1952), Mahler (1975), Mahler, Pine and Bergman (1975), and Kernberg (1976), describe how psychological growth and development occur, and emphasize the importance

8 Introduction

of early relationships, describing how these can continue to affect and impact relationships throughout one’s life. No unified object-relations theory exists as with many other theories. Self-psychology incorporates many of the concepts of OR theories and emphasizes the importance of the development of the “self”. Kohut (1977) describes psychological development with a focus on narcissism, or self-focus. He proposed that there was age-appropriate narcissism, which takes it away from always being considered as pathological and proposes that infantile narcissism, when developed along expected lines, can become transformed into healthy adult narcissism characterized by wisdom, empathy, and an appropriate sense of humor.

Creative Activities What creative activities are described and presented? There are numerous creative activities that could be helpful, but this presentation is limited to a few. They were selected because the described uses do not require specialized training, they are not an emphasis or focus for therapy, they are easy to implement, these can be effective for the group as a whole as they involve the entire group while at the same time they speak of the individual member’s personal situation or concern, and they can reveal nonconscious and unconscious material. The major categories of expressive processes presented are art activities; writing; imagery, mindfulness, and music; movement, exercise, dance, drama, simulation, and role play; collage, flats, and scrapbooks. These categories are briefly described with more extensive discussions and presentations provided in their focus chapters. Art activities include drawing and collage and are proposed as a means for facilitating expression of difficult, complex, and ambiguous concepts and feelings that could be helpful for members’ understanding. These can help moderate the effects of defense mechanisms such as intellectualizing, can provide means for less verbal members to contribute, and reveal nonconscious experiencing. These exercises are not used or interpreted as they would be in art therapy, as that requires specialized training. Drawing is used to focus and facilitate expression. Writing is a form of expression that can be used in many ways. Presented here are uses for journals, poems, and personal stories. Writing can aid in recall, expansion of feelings and ideas, provide for the emergence of new perspectives, and tap into the person’s creativity. It is a personal and private way to recall, expand, and/or express, but can then contribute to personal learning and understanding in the group. The category for movement incorporates dance, drama, role play and physical exercise. Movement will be presented as a means to energize, to connect or reconnect to the body, and to become aware of the messages the body may be sending. Simple movement activities are presented that can be performed by people of all ages, and there will be very few who cannot do most

Introduction

9

or all of the activities. Dance, like music and art can be the focus and emphasis for therapy, but the activities here, again, only use this modality as a stimulus to access important material and understanding for group members. The leader does not have to be trained in dance therapy to use these activities. Exercise is an activity that is also a means for focusing on one’s body. What is presented is not intended to be a regime of exercising, but to use some exercise moves as stimuli for expression and discussion. Simple stretching moves, cardio-vascular activities, and the like are the focus for these exercises. Drama and role play are categorized with movement as they call for group members to move and interact, and to be aware of what they are experiencing in the moment. Acting can promote empathy and understanding of oneself and of others as other perspectives are assumed. Role play is a specific technique that is similar to drama, but usually is built around real circumstances and personalities. Assuming the role of the other person can produce new learning and a new perspective. The next category includes imagery, mindfulness, and music. Imagery activities provide a way to visualize concepts that are difficult to describe with words but can be a technique to clarify worries and concerns, hopes and aspirations for the future, current issues and concerns that are just below the level of consciousness, and provide access to past experiences. Mindfulness is a technique to teach concentration and focus for the present, to be aware of oneself and all manner of the self-experiencing in the here and now, and to become a self-soothing technique. While mindfulness has evidence of its efficacy in alleviating physical and psychological stress and health conditions, it is also valuable for teaching members how to manage and contain uncomfortable feelings. Music is presented here to function just as drawing does, as a stimulus but not as the major focus for therapy. Music has the power to evoke emotions, and the use of music can facilitate members accessing and expressing their feelings. The final category has a collection of activities – stories, memories, photography, visual journals and flats. Stories such as fairy tales can also help adults to access some nonconscious and unconscious material. Bettleheim (1976), Diekmann (1997), and Holton (1995) describe these as having the potential for a rich source of knowledge about developmental lacks and existential concerns. Fairy tales describe parts of a successful individuation process and the need and rewards for moral development. It is important to note that these tales tend to be non-threatening and assist to help reframe existential issues, allow the personal meaning of a story to emerge and associated with current experiencing, and stimulates the search of the unconscious for greater personal understanding. Memory activities revolve around the creative activity of scrapbooks. Scrapbooks are a longer-term group project and are used here as a means to gather fragmented pieces of self and memories, not as the usual scrapbooks, but are more a book about oneself – or to be of assistance in the grieving process. Photography and visual journals are activities that can guide self-expression for current experiencing. This

10 Introduction

can be especially helpful when group members’ current experiencing is difficult for them to express fully in words. Flats are patterned after Flat Stanley and used here as a way to communicate and build relations when people are socially isolated, separated by geography or other means, as well as for group dilemmas. Selecting an Activity Most of the activities that are described in this book can be completed in the group session, while others will need more time for completion of the product and can be assigned as homework. Activities outside the group would then be brought back to the group for the expansion and debriefing phase. Group leaders will want to select the kind of activity to use based on group members’ needs, characteristics, and abilities, and to choose particular exercises to fit these and the time available in a session. It is highly recommended that all exercises, other than the extensive ones assigned as homework, be entirely completed in that session, including the expansion phase, and be carried over to a subsequence session. Leaders also need to be prepared that homework might not be completed by all group members, as this will necessitate their having to deal with those who did the work, and those who did not.

Ethical Considerations Professionally competent group leaders follow the ethical codes of their professional organizations or licensing boards. Central to the use of creative activities are several ethical principles that are common to all mental health professionals. These include to do no harm, the therapeutic relationship, confidentiality and its limits, responsibilities and competence, professional relationships, and a process for resolving ethical issues. Do No Harm The primary ethical concern when using creative activities is to do no harm. Dimidjian and Hollon (2010) define treatment harm as being caused by the treatment and harm that is or was not an inherent part of the problem. Using this perspective, harm when using creative activities in a group setting would be defined as being caused by the activity and harm that was not a part of the presenting problem, member distress from interacting that is not attended to, treatment that causes the member to experience problems in domains other than the target problem, and the presenting problem or identified concern becomes worse with treatment. Prevention skills that can help reduce or eliminate the possibility of engaging in potentially harmful treatment include the following with sample studies cited to substantiate their efficacy.

Introduction











11

Enhance the therapeutic relationship (Horvath & Bedi, 2002; Martin et al., 2000). Understanding how the therapist contributes to negative interactions, ruptures in the therapeutic alliance and their influences, and impact on improving therapeutic outcomes (Binder & Strupp, 1997; Castonguay et al., 2004). Continually monitor and manage countertransference (Gelso et al., 2002). Identify transference without analyzing it (Crits-Christoph & Gibbons, 2002). Restrict interpretations, especially when treating personality disorders (Schut et al., 2005). Recognize that the best predictor of outcomes is the level of the therapist’s developed self (Wampold, 2006).

The therapeutic relationship is a special one that sets the frame for what can be built between the group leader and members. This relationship encompasses more than the leader’s personal development, knowledge, and skills; it also includes some professional responsibilities and tasks that are ethical requirements. The group leader who attends to these is helping to promote an atmosphere that can lead to feelings of trust and safety necessary for reduction of ambiguity, mistrust, and resistance; and to promote cooperation, self-disclosure, and reflection. The tasks and responsibilities for ethically appropriate therapeutic relationships are categorized as the group leaders’ personal development and professional preparation, documentation, and client preparation. The personal development and professional preparation of group leaders are central to the therapeutic relationship and group development. Personal development is central in the reduction of possible countertransference to protect members, and in developing the inner states that are critical for developing the therapeutic relationship. Group leaders must constantly stay in touch with their personal needs and values so that these are not imposed on group members. Professional preparation includes the academic knowledge, skills training, and appropriate supervised practice. Another major component in this preparation is cultural sensitivity. Group leaders will most likely have a variety of cultures in every group although, on the surface, members can appear to be homogenous, and it is very necessary that leaders have cultural sensitivity and competence. Further, cultural sensitivity can assist the leader in formulating reasonable treatment plans and making appropriate interventions. While it may not be possible to fully understand all the cultural differences you may encounter, it is ethically responsible to ensure that you are culturally aware and sensitive, to learn as much as possible about your members’ cultures, and to consult about these when you do not have sufficient information about a particular culture.

12 Introduction

Treatment plans are an ethical responsibility, and are generally required by the treatment facility, and by insurers. Your treatment plans can be a guide for working with individual members in the group, and you are encouraged to develop these as a part of your planning for the group. Treatment plans should reflect an integration of treatments; be realistic, objective and rational; and should be consistent with clients’ abilities. It can be very helpful to develop these in collaboration with other treatment professionals associated with members, and with the individual member. The latter may not be possible with some members because of impairment, but even they should be informed and encouraged to try to participate in their treatment planning. Informed consent means that members understand what is proposed, are able to evaluate the risks to them personally, and are not being forced or coerced into participation without sufficient information. There is always the matter of involuntary participation, such as court-ordered treatment; but even under these circumstances members should be fully informed and provide signed forms to document that you did provide the information. Confidentiality and Its Limits There are numerous reasons to specifically address confidentiality and group leaders should make special efforts to openly discuss concerns members may have about the leader’s responsibility, and the limitations on what can, or cannot, be kept confidential. This includes the reporting of information with other treatment professionals and concerned bodies such as insurance companies. Group leaders should know and attend to the following ethical responsibilities.










Understand members’ cultural context for maintaining confidentiality. Some conditions and illnesses are considered shameful in some cultures, and there is a stigma attached to them. Do not assume that members have the same cultural context as yours. Keep a respect for privacy. Just as there are cultural sensitivities, there can be gender-related sensitivities and age-related ones. What may seem unimportant to you may be very shame inducing for others. Proper and planned termination. It is not ethically responsible to abandon clients, and most codes of ethics strictly prohibits this action. If you find that you cannot assist the client for any reason such as lack of proper training, significant countertransference issues, personal illnesses or crises; it is your ethical responsibility to provide appropriate referral and/ or other transfer of services. Remember that clients must consent in order for you to share information, even with other treatment professionals, and you need to obtain their written consent before sharing any information.

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13

Clients should be fully informed about the need to share information with other treatment professionals, the limits of your ability to maintain confidentiality with them, and the purpose for sharing information. It is essential that security be maintained when sharing or transmitting information about clients. This can mean that you do not share any information in public places, such as hallways, and lunchrooms, and that you are aware of the lack of security for phones, fax, email, voice mail, answering machines and so on, and that you take proper precautions. Court-ordered disclosures should be specified in advance, understood by all parties concerned, prevented where possible, and narrowly defined. In all cases, the amount of information should be limited and restricted to essential information. The restrictions for court-ordered disclosures also apply to third-party payers, and only when the client authorizes release of information. Group leaders have an ethical responsibility to report when a client exhibits clear and eminent danger to self and/or others, and when there is a contagious life-threatening disease. Group leaders are also advised to be aware and follow state, federal, local, and institutional laws and policies for reporting on these conditions.

Professional Responsibility All codes of ethics for mental health professionals have standards for education, training, and supervised experiences. It is your responsibility to secure needed education and so on, and to only practice within the scope of their training.











Knowledge of standards of practice guidelines as specified by your licensure and certification, and the ethics for your profession. Secure the needed training, education, and other experience specified as basic for professional competence. Know, understand, and abide by the state and national professional standards for credentialing. When practicing new specialties, techniques and the like, ensure that you receive the proper professional experience. Consult when there are ethical issues, concerns, and dilemmas. Seek out and obtain appropriate continuing education opportunities. Take care to be clear and accurate in presenting your credentials. Take responsibility to report when you are impaired and to obtain treatment. Take responsibility to ensure that your practice is nondiscriminatory. Seek appropriate consultation and collaboration to benefit clients.

14 Introduction

Process for Resolving Ethical Issues Most processes for resolving ethical issues place considerable responsibility on the group leader to recognize when ethics violations and conflicts exist, to understand when and how to address these, and be willing to uphold professional standards. A process for resolution includes all of the following.




A complete knowledge of the ethics of the profession. Understanding of if and when the law conflicts with ethics, and the possible consequences. Understanding of when and how to report suspected violations, and the need for consultation.

The Group Leader’s Preparation A significant part of the leader’s preparation to establish a conducive group climate for optimum use of creative activities, as well as establishing a therapeutic relationship, includes the leader’s development of relating attributes, communication skills, a developed self to provide emotional presence, knowledge, and techniques for facilitating groups, empathic responding, and empathic failure repair. These are basic and fundamental to group leadership regardless of the type of group but may be even more important when incorporating creative activities into the group and are presented first. Next presented are the basics of the group leader’s preparation for developing the therapeutic relationship, attention to process, awareness of the potential for narcissistic injury, and the possible emotional states of group members, all of which are critical to the group’s success and especially for using creative activities (Yalom & Leszcz, 2005; Egan, 2006). Most of the activities presented in this book can be best facilitated after safety and trust has been established in the group, and the group leader’s ability to form a therapeutic relationship is critical. This relationship allows group members to believe that the group leader will take care of them, that relationships in the group will be constructive, that the possibilities for growth, development, and healing can be realized, and that confidential material will remain confidential.

The Group Leader’s Development Relating attributes include warmth, caring, concern, tolerance, acceptance, genuineness, and respect. Rogers (1970) termed much of this as unconditional positive regard where the therapist perceives the client as capable, worthwhile, and valued. These are more the outcomes for personal development and cannot be taught and learned; the person has to have these as a part of their self.

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These characteristics can be extremely important when implementing creative activities as members can be confronted with aspects of self that may trigger guilt and shame. When this occurs, it is vital that the group leader is able to communicate nonverbally and verbally their caring and concern, acceptance of the person even with flaws, and to be encouraging and supportive of their ability to tolerate and benefit from what emerged. The basic relating attributes are central to conveying this and cannot be taught as they have to be an integral part of the leader. Techniques and skills can be taught and learned; attributes cannot. Communication skills on the other hand, can be taught and learned. Listening for feelings and content, an ability to express a wide variety of feelings, talking in concrete and direct terms that are understood by the other person, understanding the role of questions, and giving verbal encouragement and support are the most basic communication skills that have applications in all kinds of interpersonal relationships, not just in therapy. The group leader must understand and listen for the underlying feelings, as the group member(s) may not be aware of these on a conscious level. This is where the skill of the group leader can be helpful, to assist the members in expressing those feelings, or expressing difficult feelings, or even just learning how to express feelings. Activities can and do trigger feelings, others can emerge as members hear about others’ reactions and experiences, and a vital part of the group process is the focus on feelings and their expression. Indeed, many of the creative activities have feelings as a central focus and emphasis. The importance of the group leader’s self-development has considerable support in the literature on effective group leadership. Studies support the proposal that the developed self of the group leader plays a significant role; such as constructive use of countertransference to understand members’ experiencing, to manage and contain intense and difficult emotions, to provide an emotional presence where members are heard and understood, and to be empathic. (Yalom & Leszcz, 2005; Alonso & Rutan, 1996; Gans & Alonso, 1998; Horwitz, 2000). Constructive use of countertransference refers to the leader’s ability to know and understand what they are feeling, the roots or antecedents of those feelings, and to be able to use these to better understand the group member(s). Managing and containing intense and difficult emotions will be a task for the group leader to model these for group members. Some group members may be fearful of their emotions, and the emotions of others, fearing that they will become enmeshed or overwhelmed, that they will be taken over by others’ feelings to the point where they feel out of control. The group can be a good place to learn that difficult and intense emotions can be experienced without loss of control. Group leaders, of course, have to be proficient at expressing their emotions, as well as being able to manage and control them, and this is a part of their self-development.

16 Introduction

The self-development of the group leader calls for an understanding of their unresolved family of origin issues and concerns, past experiences that carry unfinished business, and personal undeveloped narcissism (Yalom & Lezcz, 2005; Brown, 2009). These must be examined and acknowledged as they can be the conscious, nonconscious, and unconscious factors that impact the group and its members.

Some Basic Skills and Attributes There are some basic group leadership skills and attributes. Critical skills include a knowledge base, empathic responding, recognizing empathic failures and facilitating their repair, attending to group process, preventing narcissistic injury and an awareness of group members’ emotional states. A knowledge base about groups and techniques is also basic, and these are covered more fully in Chapter 4. Group leaders need a thorough grounding in the fundamentals of group facilitation such as group stages of development, therapeutic factors, and phases of group member development (Brown, 2009; Trotzer, 2011). This is the information that leads to making informed choices and decisions about when and how to use creative activities in a way that promotes group member development. Empathic responding is essential although it is recognized that the group leader will find it impossible to be empathic with everyone all the time. However, the group leader must have the capacity for empathic responding even if the leader cannot be empathic at that time. Being empathic means entering the world of the other person to feel what that person is feeling without losing the sense of oneself as a separate and distinct individual. Empathic responding means that the content and feelings of the other person are understood, but this is on a more cognitive level. The leader is not feeling what the other person feels, they are able to identify and communicate what that person is feeling. Central to being empathic and responding empathically is that this is conveyed to the other person in words. Nonverbal communication is not sufficient, and can be misunderstood and misleading. Empathic failure and repair are essential tasks for the group leader and can be especially helpful when implementing creative activities. While other group members can and do repair empathic failures, Kohut (1977) and Brown (2021) propose that this is a primary task for the therapist. What are some indicators that there has been an empathic failure that need attention?






A group member self-discloses and no one makes a response. Someone expresses a feeling that is not acknowledged, and/or the discussion changes topics. A group member is silently crying and no one says anything. Interactions among group members or with the leader become increasingly tense, or circular, or seem stuck. A disclosure is minimized, ignored, or a trivial response is given.

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These are a few examples, there are many more. What is important to know is that neglecting to repair the empathic failure impacts that person and other group members who may then fear that they too will not be understood or receive an empathic response. Attending to group process is an advanced group leadership skill, as is making process commentary, but these are also facilitative to the group and its members. Process is the here and now experience in the group that describes how the group is functioning, the quality of relationships between and among group leaders and with the leader, the emotional experiences and reactions of the group, and the group’s strongest desires and fears. (Brown, 2003, p. 228). Yalom (2005) proposes that process commentary illuminates what is taking place in the group and may be impacting the group’s functioning without members’ awareness of what is taking place. Focusing on and intervening with individuals is productive, but until group members learn how to coattail, that is, use what you are doing with one individual to work on their personal issues, the leader is not doing group therapy or group counseling but rather is doing individual therapy in a group setting. Group therapy and group counseling that use the resources of the group to help individuals is very effective and allows all members to work at the same time. Making group level process commentary allows the leader to work with all group members. Some specific indices that indicate the need for group process commentary are:







Behaviors of the group, what the group is doing, or is not doing Feelings generated in the leader Feelings noted in members from their nonverbal behavior that seem important but are not verbalized Impact of behaviors on members but they do not respond or acknowledge the impact Links between issues, concerns, and feelings Themes that emerge in group.

When using group as a whole process commentary, a group leader will find it helpful to be able to identify the session’s theme, the behaviors the group use that reflects resistance, how the group manages conflict and difficult member behaviors, feelings that are directly and openly expressed and those that are not, empathic failures and repair, and how the group is using its energy, or not. Preventing narcissistic injury or wounding starts with an awareness of what it is and how it occurs. Reich (1972) conceptualized narcissistic injury as the

18 Introduction

hurt or wound that occurs to the developing self and is experienced by the receiver with uncontrollable feelings of helplessness, anxiety, and rage. The person’s self-esteem is negatively affected, and these injuries continue to exert their negative influences and can be intensified when additional wounding occurs. Reich (1972) is not clear if the additional wounding is a reinjury of the initial wound or is a collection of different wounds. Kohut (1977) describes narcissistic injuries as disturbances of narcissistic balance – usually easily recognizable by the painful affect of embarrassment or shame that is experienced, and characterizes the response as one of “shame and uncontrollable rage”. Thus, a group leader has to maintain awareness that narcissistic injury can and does occur in groups, that the individual is severely impacted by this and their functioning in the group, and to work to reduce the incidents, and repair the wounding. Narcissistic wounding can occur when others, including the group leader, make insensitive remarks that seem to insult or invalidate the receiver, when microaggressions occur in the group, when the person feels that something shameful has been revealed about them, when scapegoated or attacked, and in other such circumstances. All of these cannot be prevented as the narcissistic wounding is unique, personal and may differ for each group member, but the group leader has to stay aware of the potential for such injuries and intervene when noticed. Responses by group members can include withdrawal, silence, becoming combative, premature termination, and other such negative responses. Repair of narcissistic wounding can be difficult as the receiver may not acknowledge the wounding, discount the impact on them, and/or become resistant to any attempt to repair it. Kohut (1977) proposes that the repair is accomplished by mirroring and empathic responding by the leader. A major consideration when using creative activities is the emotional state of members. Tuning into states such as extent of emotional vulnerability, defensiveness and resistance and how these are manifested, the known and hidden self, the potential for growth and development, and their self-perceptions and self-esteem help leaders in the decision-making process to select and use appropriate creative activities. Careful attending to the emotional vulnerability allows the group leader to select the activities that will be beneficial, not harmful, by producing intense and sometimes overwhelming affect that is difficulty to overcome or to control for that person or for several group members. Safety is a prime concern, and not recognizing the emotional vulnerability of one or more group members can make the group not feel safe for many members. All group members will have and exhibit some defensiveness and resistance, and the group leader can address these with some creative activities that help to bypass them, and allow the member to access important information about self. It is not necessary or helpful to term members as defensive or resistance, it is much more helpful to allow them to decide when or if to lower their

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defenses, or reduce their resistance. Since it is likely, if there is group level defensiveness and resistance, that each member is displaying these in a different manner and form, the group leader can address all at the same time with an appropriate well-chosen creative activity.

Judicious Use of Creative Activities One of the benefits of participating in group therapy is becoming aware of what is known and what is unknown about oneself. Discovering, and rediscovering parts of self can be very rewarding, but is not easy to accomplish. After all, there are many facets to oneself, and some are more visible to the person than are others. Creative activities can point the way and guide the group members to explore, discover, and enhance known and unknown parts of self, to build and/or change parts of self, and to become a more fully aware and authentic person. Therapy is undertaken with the hope and possibility of growth and development as well as providing avenues for problem-solving and decision-making. Growth and development of the self, of relationships, of knowing and being are all possible, and are enhanced with the use of creative activities. Considerable growth can and does occur during group sessions, participation in creative activities, and as these promote the willingness for self-exploration and self-enhancement, can be stimulating and inspiring. Essential in choosing and using creative activities is the group leader’s knowledge and understanding of group members’ self-perceptions and selfesteem (Crits-Christoph et al., 2006). How members perceive and value their selves provides clues as to which creative activities can be used to increase their awareness, be affirming of the self, focus on strengths and capitalize on these, and guide them to explore sensitive areas which are part of the growth and change process. Since perceptions and esteem are likely to vary among group members, creative activities allow the exploration and expansion of these to occur for each member wherever they may be on these dimensions.

Summary This chapter covered a rationale for using creative activities, descriptions for those presented in the book, the background evidence for the efficacy of experiential learning, ethics related to using these activities, and some of the basic leader attributes, skills, self-development, and basic knowledge. Chapters 2 and 3 discuss the procedures, processes and guidelines for how to implement creative activities and how to guide members’ self-exploration. Chapters 4 to 8 describe the categories of activities with examples that can be used. Chapter 9 presents the background for using activities in diverse settings, restrictive and virtual, and Chapter 10 presents the overview for the effectiveness of creative

20 Introduction

activities to address physical, emotional, and relational conditions. The final chapter presents applications of creative activities for groups and some group dilemmas, and for managing group processes.

References Alonso, A. & Rutan, J. S. (1993). Character change in group therapy. International Journal of Group Psychotherapy, 43, 439–451. Alonso, A. & Rutan, J. S. (1996). Separation and individuation in the group leader. International Journal of Group Psychotherapy, 46, 149–162. Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford. Bettelheim, B. (1976). The uses of enchantment: The meaning and importance of fairy tales. New York: Knopf. Binder, J. & Strupp, H. (1997). “Negative process”: A recurrently discovered and underestimated facet of therapeutic process and outcome in the individual psychotherapy of adults. Clinical Psychology: Science and Practice, 4, 121–139. Brown, N. (2003). Conceptualizing process. International Journal of Group Psychotherapy, 53 (2), 225–243. Brown, N. (2006). Reconceptualizing difficult groups and difficult members. Journal of Contemporary Psychotherapy, 36(3), 145–150. Brown, N. (2009). Becoming a group leader. Upper Saddle River, NJ: Pearson Education. Brown, N. W. (2021). The significance and importance of repairing empathic failures. In Women, Intersectionality, and Power in Group Psychotherapy Leadership, (pp. 185–200). New York: Routledge. Castonguay, L., Schut, A., Aikins, D., Constantino, M., Laurenceau, J., Bologh, L., & Burns, D. (2004). Integrative cognitive therapy for depression: A preliminary investigation. Journal of Psychotherapy Integration, 14, 4–20. Corey, G. (2009). Theory and practice of counseling and psychotherapy. (8th ed.) Belmont CA: Brooks/Cole. Crits-Christoph, P. & Gibbons, M. (2002). Relational interpretations. In J. C. Norcross (Ed.) Psychotherapy relationships that work: Therapist contributions and responsiveness to patients, (pp. 285–300). New York: Oxford University Press. Crits-Christoph, P., Gibbons, M., Crits-Christoph, K., Narduci, J., Schamberger, M., & Gallop, R. (2006). Can therapists be trained to improve their alliances: A preliminary study of alliance-fostering psychotherapy. Psychotherapy Research, 16, 268–281. Dieckmann, H. (1997). Fairy-tales in psychotherapy. Journal of Analytical Psychology, 42(2), 253–268. Dimidjian, W. & Hollon, S. (2010). How would we know if psychotherapy were harmful? American Psychologist, 65(1), 21–33. doi:10.1037/a0017299. Egan, G. (2006). The skilled helper (8th ed.). Pacific Grove, CA: Brooks/Cole. Ellis, A. (1997). The evolution of Albert Ellis and rational emotive behavior therapy. In J. K. Zeig (Ed.) The evolution of psychotherapy: The third conference, (pp. 69–82). New York: Brunner/Mazel. Gans, J. & Alonso, A. (1998). Difficult patients: Their construction in group therapy. International Journal of Group Psychotherapy, 48(3), 311–326.

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Gelso, C. J., Latts, M. G., Gomez, M., & Fassinger, R. (2002). Countertransference management and therapy outcomes: An initial evaluation. Journal of Clinical Psychology, 58, 861–867. Holton, C. (1995). Once upon a time served: Therapeutic application of fairy tales within a correctional environment. International Journal of Offender Therapy and Comparative Criminology, 39(3), 210–221. Horvath, A. & Bedi, R. (2002). The alliance. In J. Norcross (Ed.) Psychotherapy relationships that work: Therapist contributions and responsiveness to patients, (pp. 37–70). New York: Oxford University Press. Horwitz, L. (2000). Narcissistic leadership in psychotherapy groups. International Journal of Group Psychotherapy, 50(2), 219–235. Kernberg, O. F. (1976). Technical considerations in the treatment of borderline personality organization. Journal of the American Psychoanalytic Association, 24(4), 795–829. Klein, M. (1952). The origins of transference. In Envy and gratitude and other works 1946–1963. New York: Delta. Kohut, H. (1977). The restoration of the self. Madison, CT: International Universities Press. Lazarus, A. (1989). The practice of multimodal therapy. Baltimore MD: John Hopkins University Press. Lewin, K. (1944). Dynamics of group action. Educational Leadership, 1(4), 195–200. Linenhan, M. (1993). Cognitive–behavioral therapy for borderline personality disorder. New York: Guilford. Mahler, M. (1975). On the current status of the infantile neurosis. Journal of the American Psychoanalytic Association, 23(2), 327–333. Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York: Basic. Martin, D., Garske, J., & Davis, M. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68, 438–450. Meichenbaum, D. (1977). Cognitive-behavior modification: An integrative approach. New York: Plenum. Reich, W. (1972). Character analysis. New York: Simon & Schuster. (Original work published 1945) Rogers, C. (1970). On encounter groups. New York: Harper & Row. Schut, A., Castonguay, L., Flanagan, K., Yamasaki, A., Barber, J., Bedics, J., & Smith, T. (2005). Therapist interpretation, patient-therapist interpersonal process and outcome in psychodynamic psychotherapy for avoidant personality disorder. Psychotherapy: Theory, Research, Practice, Training, 42, 494–511. Trotzer, J. (2011). Personhood of the leader. In Robert K. Conyne (Ed.) The Oxford Handbook of Group Counseling, (pp. 287–306). New York: Oxford University Press. Wampold, B. (2006). The psychotherapist. In J. Norcross, L. Beulter, & R. Levant (Eds.), Evidence-based practices in mental health: Debate and dialogues on fundamental questions, (pp. 200–208). Washington, DC: American Psychological Association. Yalom, I. & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books.

Chapter 2

Procedures and Process for Use of Creative Activities

Introduction This chapter presents the fundamental principles and assumptions about the group and its members that guide the use of creative and expressive activities, the general procedures for conducting the expressive activities, and a process for guiding personal exploration and enhancement to facilitate an understanding of what emerges for group members during the experience. The understanding and knowledge of the group leader is essential for helping group members benefit from participating in the creative activities.

Fundamental Principles There are ten principles to guide the use of creative activities: personal experiencing, meanings that emerge, how the inner world is reflected, current wishes and the like, reduce defensiveness, acceptance, developmental and existential issues, continued processing, evoking intense emotions, and basic ethical concerns. Each member’s personal experiences are unique, and their responses are a combination of many factors such as past experiences, family of origin factors, personality, current physical and emotional states, and so on. Thus, each group member’s experiencing will be unique and personally relevant for them. The meanings for the product that emerge from the activity lie within that person as they are currently, and even past experiences are perceived from a current perspective. Elements of the product and/or outcome are reflective of the inner world of the person at that time, including some of the possible influences of their past cognitive and emotional states. What is helpful is when these can be explored to understand their continuing impact on current experiencing, such as the impact of past relationships on current ones. The products or outcomes provide clues for the person’s current wishes, desires, and needs. Cues carry personal implications; some are below conscious awareness, and some may even be from the unconscious. Cues are best explored, and meanings extracted by that person and not by others such as the leader, and this is highly recommended in this book. Reducing defensiveness is best accomplished DOI: 10.4324/9781003251989-2

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through allowing the group member to draw their own meanings, observations, and conclusions, and by the group leader refraining from offering interpretations. New pathways of understanding and insight can be opened for the group member because their energy goes into understanding rather than to fending off the perceived threatening material and/or the group leader’s interpretation. Acceptance of what emerges during the activity is increased and tolerated when the group member provides meaning for the products. The threat or danger to the self from the material is managed better by being under the control of that group member. Developmental and existential issues can be tapped by some activities. These are issues and concerns that reemerge throughout life, even when resolved for the present. Many group members may be unaware that this reemergence is expected, or may they not understand the impact these can and do have on their current and future functioning. Expressive activities can activate them, bring them to consciousness, allow for their expression, and to connect with other group members who are struggling with the same or similar issues and concerns. These connections can be relieving, affirming, and promote universality. All of the possible learning, understanding, and insight may or may not happen in the group setting and can continue after the activity is completed. The expressive activities are stimuli material so group members can continue to reflect on what they experienced, and additional learning, understanding, and even repressed memories can emerge after the activity is completed, and between group sessions. The continued processing of the experience can contribute to their growth, development, and healing. In addition, intense and unexpected emotions may arise during an activity, and these must be contained and managed during the session. The group leader must be mentally and emotionally prepared to cope with members’ intense emotions as these can be an outcome for an activity. In this event, it is necessary to ensure that the member(s) do not become mired or overwhelmed with the intensity, and that they do not leave the session with considerable emotional intensity. Ethical principles, as described in Chapter 1, guide the use of expressive activities. A variety of expressive activities are presented in the book and these were chosen as examples that do not require specialized training. However, it is suggested that readers do get some training before implementing these in the groups that they lead. It is not sufficient to have experienced these in their training or therapy and think they are valuable – some more formal instruction is generally helpful. Workshops, conference institutes, and other means of training could be used.

General Guiding Assumptions Six major general assumptions guide this presentation: the focus is on the group as a whole, clinical issues are the focus, the group has a dilemma and

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the leader may have tried to intervene without success, the dilemma affects all group members although members may vary in their personal reasons for the dilemma, the group leader can also mirror and contain the dilemma, and the group dilemma reflects resistance, confusion, fear, and/or uncertainty. Group as a whole focus One or more members may be reflecting the dilemma and there is a tendency to focus on these members. Attending to the group as a whole allows the leader to address each member’s concern, to be inclusive, lessens the potential for scapegoating, and demonstrates understanding and empathy at a deep level for all members. Clinical issues Clinical issues are the focus as dilemmas can be reflections of deep-seated issues, concerns, and problems that are usually the focus for clinical groups. Other types of groups that are more short term or that have a more cognitive focus may not have sufficient numbers of sessions to adequately deal with the sensitive material that can emerge from some creative activities. Expressive processes could be used as a means to relieve tension for these shorter term or more cognitive groups or help with encouraging expression of feelings, or as aids to help members talk about difficult topics. Tried interventions were ineffective Group leaders are likely to have tried several interventions that were not successful since the dilemmas continue to exist. Interventions may have focused on individual members, exploration of feelings, group process commentary, and other such usual interventions that worked for the leader in the past. Individual interventions do not work because the dilemma is a shared group member concern, although it is usually expressed differently for each member. Exploration of feelings do not seem to be effective because no understanding occurs and venting alone isn’t sufficient; or some members may be suppressing, repressing, or denying feelings and these are not being expressed; or members may be confused about their feelings and unable to sort through them. Reasons vary Most often, members will have different reasons and sources for their reactions. For example, some could be experiencing transference, some are projecting, some fear destruction of the self, and others could be so fearful of what could emerge that they shut down. The group leader may not know or

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be aware of all of the individual reasons, and each may need a different intervention, but the entire group is still impacted and reacting. The leader mirrors and contains The group leader’s inner experiencing can be a rich source of information about what the group is experiencing. Leaders mirror and contain affect for the group, and these are what the leader’s inner experiencing can be reflecting. The leader’s level of personal development to reduce countertransference, (Gelso & Hays, 2007) self-understanding to reduce projecting, and the ability to be aware of here and now experiencing, and monitoring of their possible countertransference and projecting, permits the leader to judge the validity of their inner experiencing as mirroring and containing something for the group. Reflects resistance, confusion, fear or uncertainty The group members’ reactions will usually be resistance, confusion, fear and/or uncertainty. Resistance to what can emerge about oneself, confusion about what is being felt but not understanding one’s feelings, confusion about the dissonance in the group and its source(s), fear of destruction or abandonment of the self, and/or uncertainty with all its accompanying terror. Guiding Assumptions About Group Members Eight assumptions are made about the group members and about dilemmas that can be addressed with creative activities. Members’ unique contributions All members contribute to the group’s dilemma, and each member makes a unique contribution. Some members can opt for deflecting tactics, some withdraw and are not emotionally present, some may become more active but the activity lacks meaning or purpose, members may engage in conflict that does not get resolved, there can be sniping and unflattering remarks made to and about each other, refusal to explore feelings, and other actions that bring the group to the dilemma. No one person institutes or maintains the dilemma, and it is the group leader’s responsibility to recognize each contribution. Members’ histories and personalities differ This may seem obvious, but it bears repeating. Each member brings a different personality and history to the group, and these, too, contribute to the dilemma and to their specific reactions. Selecting an intervention under these

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circumstances can be a challenging endeavor as what might be useful for one member could be so threatening for another member that they would retreat even further, or worse. Further, there are family of origin and other past experiences that are influential, but these may not have been revealed leaving the group leader in ignorance, or the member could have repressed them, but they still continue to exert influence. Unaware Members may be unaware of their fears and fantasies that are influencing their reactions. Thus, when asked about their reactions, their responses are not meaningful or helpful. They are unaware and cannot articulate their inner experiencing in ways that others can understand. They resort to noncommittal responses, to telling stories, or making no response, none of which provide the leader with clues to their real concerns. At a crossroads It would not be unusual for some or all group members to be at a psychological crossroads, threshold, or boundary that produces fear and anxiety. These members can dimly sense impending changes, or even be acutely aware that change is inevitable, but still be fearful and anxious about the uncertainty and unknown personal future. Members will also vary in how they accept and use their inner resources to cope, and will display these in varying ways. Incomplete development Members can display indices of incomplete development, such as separation, individuation and narcissistic development. Since each member is unique and different, each will be at a different point for each of these lines of development. The expressive processes take these incomplete development statuses into account, and work with each member at their particular point of development. Existential concerns Yalom and Leszcz (2005) propose that existential concerns are present in every group regardless of the group’s focus, but that these concerns are not always addressed, and some may never be mentioned in some groups. However, there are also groups where some of these concerns, such as death and existential despair, are acute and prominent in the group’s discussion. Even when existential concerns are not emphasized, they can still be influential on group members.

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Varying means of making sense Group members will use varying means to try and make sense of their worlds. There are their internal forces that are not completely understood or fully integrated. In addition, there are external forces that impact them over which they have little or no control. For some members this seems chaotic and directionless, and they have trouble sorting through and making sense of them. Others can feel competent to handle one set of forces, but not both at the same time. Others can feel overwhelmed and just shut down. Each member responds in a unique way. Dilemmas as defenses Think of the group’s dilemma as a defense mechanism, but what it is defending against is unknown, may be different for each group member, and each uses a different defense mechanism although they collectively share in producing the dilemma. These variations can make it difficult for a group leader to zero in on the commonality because all they are presented with are the differences. Basic Group Conditions for Use of Creative Activities There are several basic group conditions that guide the use of creative activities: sufficient safety and trust has been developed; there are rules and guidelines for participation, and for giving and receiving feedback; the group needs assistance to further its functioning; and a problem-solving strategy is needed. It is critical to develop sufficient safety and trust before conducting most of the described activities. The only exceptions may be when an activity is used to facilitate introduction of members where the activity is non-threatening and does not call for disclosure of sensitive personal material; or using an activity to just play and have fun. Safety and trust will facilitate self-disclosure by members, and the level to which they are willing to reveal the real self. Group leaders will usually have collaboratively established rules and guidelines for participation, reviewed these with members to get their commitment, and members will generally know what is expected for communication, disclosure, and providing feedback to each other. It is recommended that members be put in charge of their disclosure to decide when and how much to disclose, and that neither the leader nor other members push for a deeper level of disclosure. It is also helpful if members know that courtesy and civility are expected in relating and communicating among each other, but not to the extent where nothing significant is communicated. Labeling, calling names, being disrespectful, and any activity that has the potential for shaming, evoking defensiveness, or provoking aggressive responses should be prohibited.

28 Procedures and Process for Use of Creative Activities

Relationships are enhanced when the members in the relationship(s) can be open and direct with each other, but that also carries the responsibility of being tolerant, respectful, and mindful when giving and receiving feedback. It is helpful for the group leader to teach group members constructive ways to provide feedback, and to help members learn how to receive and accept feedback. These competencies will facilitate personal learning from the creative activities. There are times when the group needs assistance to express their thoughts, ideas, and feelings in appropriate ways. One of the reasons that some difficult situations or group dilemmas occur is that members are reluctant to express negative feelings because they fear the fantasized outcomes to be destructive, either to them, to the leader, or to the group. The leader’s expertise and use of creative activities can facilitate expression and demonstrate how to do so appropriately. Most of all, members can learn that feedback need not be negative or destructive. Group members can also learn problem-solving through participation in creative activities, especially when things are complex, ambiguous, and uncertain as these occur in the group setting. Demonstrating that there are alternative perspectives, different means to approach a problem or dilemma, and even just the use of creativity can suggest to members that problems need not be overwhelming and frustrating to the point where nothing constructive is accomplished. In addition to the basic six assumptions there are three other assumptions that will be helpful: stage of group development; the group leader’s development and expertise; and the therapeutic relationship. The stage of group is influential when choosing an intervention as this can help decide if the group will be able to manage the emotions or other material that can emerge from the creative activity. For example, activities that can evoke irritation, aggression, or conflict would not be helpful if the group is in the second stage of development (Conflict stage). The group leader’s inner experiencing and clinical judgment are critical to resolving difficult situations and dilemmas especially when the difficulties arise in the here and now. The therapeutic relationship is also a critical component; the extent of development for the relationship, and the level of trust and safety established in the group. General Guidelines for Selecting Activities Six guidelines are recommended for selecting activities: preventing potential harm; members’ capabilities; materials; the members’ ages and stages of cognitive and emotional development; space and environmental concerns; and confidentiality and privacy concerns. Prevent potential harm for members and consider their diagnosis and backgrounds that could affect their participation. For example, reflecting on past events has

Procedures and Process for Use of Creative Activities

29

the potential for triggering distressing feelings that may be difficult for the member and/or the group to manage. Group leaders may want to reflect on what might be evoked from the activity. Members’ ableness to manipulate the materials has to be a major consideration. Physical ability to use the needed materials for the activity can be a significant barrier to their participation. The other possibility to consider in advance is the setting for the activity that could be considered as ableness such as prisons and other treatment facilities where materials could become destructive. It is extremely important that group leaders ensure the availability of needed materials in advance of implementing a creative activity. The materials should be readily at hand and in sufficient number so that group members can be assured of using the materials they want for their products. It is recommended that group leaders secure the materials well in advance of the group session. Members’ ages and stages of cognitive and emotional development are essential to consider when selecting and implementing creative activities. While most of the activities in this book are appropriate for a wide variety of group members, the group leader will still need to determine what adjustments may be needed for the particular group and their age and stage of development for an activity. Space and environmental concerns are also important. There should be sufficient space, appropriate surfaces and the like for group members to work on their products. Adaptations may be necessary such as using large hardcover books in lieu of tables for drawing and writing. Members should have sufficient space to work so that they are not interrupting or being interrupted by others. The final major concern for selecting activities is the group leader’s awareness of the members’ needs for confidentiality and privacy especially outside of the group. Some members may not have sufficient privacy to keep their products confidential in the event that they are concerned about what others may learn or understand about them. Group leaders may want to ask group members if they have these concerns, or if they want the group leader to retain their products. A major concern about confidentiality and privacy may be the need to restrict what can be disclosed on social media and have a rule that members may not share what other members did or said on their social media sites, including restrictions on taking photographs of group members and their products.

General Guidelines for Use of Creative Activities Each set or category of creative activity is unique, and specific instructions for use of each are presented in the chapter that addresses that category. There are also some general guidelines that apply to all categories of activities and these are presented in this chapter. One of the major premises for this book is that these activities should have purposeful intent. The group leader should understand the group and its members’ needs before implementing creative activities. This chapter presents the process for planning that also describes a decision-making process for selecting a suitable activity and the four phases.

30 Procedures and Process for Use of Creative Activities







The Implementation Phase presents the procedures and directions for when and how to introduce the activity, and what to do while members are creating projects. The Reporting Phase describes how to facilitate members sharing of products. The Expansion Phase has guidelines and procedures to use to guide group members to understand their products, and the feelings they had while constructing, and those during the reporting. The Enhancement Phase deepens the experience by guiding members to derive and understand meanings and associations evoked by the creative activity.

The Implementation Phase This phase includes planning, a decision-making procedure, and ethical considerations. Even experienced group leaders are encouraged to use the planning process to gain optimum outcomes. Creative activities should be planned in advance, and not impulsively used during the group session. Planning involves determining the purpose and goal(s) for the activity, selecting an activity, determining needed materials and supplies, and developing the questions that will be used to guide exploration and enhancement. When you first begin to use creative techniques, it will be helpful to write the plan. That way you can ensure that you’ve covered all the major requirements, and not have any lapses when using the activity in the group session. As you become more familiar with these and develop your personal favorites, you may not need the security of writing a plan. 1

The first step is to establish the purpose and goals for the activity. Have you identified a group need? What are you intending to accomplish? How would the activity meet the group’s need? There are numerous purposes for activities. Following are some examples of group needs, some identifiers of the need, and possible benefits from using a creative activity: a

b

c

Fear of conflict in the group. Group members seem skittish and fearful of conflict emerging in the group, and an activity such as those described in the application chapter could help reduce some of their apprehension. Defensiveness. There is considerable intellectualizing and talking about feelings rather than expressing feelings in several session. An activity could provide a means for getting around these defenses to allow members better access to their feelings, and/or facilitate expression of feelings. Low verbal skills. Group members have low verbal skills, and have difficulty expressing personal thoughts, feelings, and ideas because of

Procedures and Process for Use of Creative Activities

d

e

f

g

31

vocabulary deficits. A creative activity could facilitate their expression for these. Suppressed conflict. There is suppressed conflict in the group that is causing considerable tension and discomfort. A creative activity could relieve tension, provide a means for members to express their discomfort and concern, and/or facilitate the expression of the suppressed intense feelings. Lack of progress. The group seems stuck and discussions are circular, no meaningful progress is being made and a creative activity could assist them in expressing what is being suppressed, avoided or overlooked in the group. Ineffective emotional venting. Several members engage in continual emotional venting over several sessions about the same concern indicating that little or no understanding or problem-solving is occurring. An activity could help promote awareness and problem-solving. Group resistance. The group is avoiding or resisting a major concern, such as developing intimacy, fear of not being safe in the group, and other possible dangerous topics. An activity could help bring these concerns to expression so as to be addressed in the group.

The initial purpose for using an activity is central during the decision-making procedure (step 2 of the Implementation Phase) to select the activity that best fits the purpose, group members, and the needs of both. 2

It is more helpful to work through the decision-making procedure, rather than just using an activity, as this will allow the group leader to select an activity that is best suited for the dilemma/concern, the group and the benefit of group members. The described procedure has the following steps: a

b

Identification of the concern, barrier, or dilemma. The decisionmaking begins with specifying the concern, issue or dilemma where a creative activity could be used as an intervention. These activities should be used to tackle something that is affecting the group as a whole, and not focused on one or two members’ individual concerns. Try to be as specific as possible in this identification, and use both observable behavior and your (the group leader’s) inner experiencing. Exploration of possible creative activities as intervention alternatives. Review the kind of possible creative activity that could be used, such as art, music, writing, imagery, and others that are presented in this book. If you have used activities in groups before, you could look at the list of these, and/or consult references for suggestions. Select a creative activity that can be fully completed in the session.

32 Procedures and Process for Use of Creative Activities

c

d

e

f

g

List the possible positive and negative outcomes for each creative activity that is considered. Reflect on what is trying to be accomplished, group members’ vulnerabilities and emotional states, and the purposes and goals for the various creative activities. Think of the positive and negative aspects for each possible alternative, the known characteristics of each group member, and if there could be a negative impact or not for any member, the possible benefit for the group as a whole, and if any suggested activity could be eliminated because of members’ capacities and ability to participate. Choices will be narrowed using this process. Consider the possible impact on each individual group member. Reflect on what is known about the group members from their behaviors in group sessions, such as their defenses, arousal, and handling of difficult feelings, uncomfortable memories that can be triggered, and so on. Also consider the possible impact on each group member, such as defenses, arousal, and handling of uncomfortable memories and/or feelings. Describe the benefits on the group as a whole for using the activity. How will the group’s functioning, progress, and process be facilitated by using the creative activity? Possible benefits for the group can include increased energy and interest, assist with expression of some feelings, and reduce tension, which may help produce a group atmosphere more conducive to growth and development. New material can emerge that promotes therapeutic group factors such as universality and interpersonal learning. Take into account members’ abilities to participate. When selecting an activity, group leaders need to be concerned about group members’ abilities and competencies to participate and gain from the activity. There can be cognitive impairment, motor dexterity, and other disabilities that would interfere with their being able to fully participate. It is recommended that no activity be used where all group members cannot participate. Consider group factors such as time needed for the activity and the stage of group and ethical considerations. Estimate the time needed to introduce the activity and distribute the materials, working time to complete the product, the time needed for members to present their products and share feelings in the group, and time needed to complete the enhancing phase. Another important consideration is the stage of the group’s development. For example, an activity that focused on a deep level of self-disclosure used in the first stage of group development, where trust and safety may not be firmly or completely established, is not a good idea. Doing so could make group members feel threatened and that makes trust and safety harder to develop.

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33

Ethical considerations should also be reviewed as part of your planning. Questions such as the following should be explored:






Is there potential harm for any group member? Am I, the group leader, qualified to conduct this activity, and able to handle intense emotions that may emerge? Is any part of the activity demanding forced self-disclosure for group members? Have I provided for informed consent? Are members free to choose to not participate, and are there penalties for not participating?

Tentative selection: by this time, you have narrowed your choices to very few, or to one creative activity. If you still have more than one as a possibility, review both and evaluate their suitability for the group. Each group has its own unique set of characteristics, and you can now select the one that seems to best fit the group and its need at this time. Example Decision-Making Procedure The following is an example of working through the decision-making procedure for a group composed of adults who have no known disabilities, and where the group has met for several sessions. 1 2 3

Identification of the dilemma. The group has no energy, members are listless, feelings are not being expressed, and the atmosphere is heavy. Possible alternatives for categories of activities. Positive and negative aspects for each possible activity category: a

b

c

d 4

Fairy tale – positive aspect – relieve tension and focus thoughts. Negative aspect – completion may take more time than is available in a session. Drawing – positive aspect – provides a nonverbal way to express feelings. Negative aspects – members may feel judged on artistic ability, sufficient materials may not be available. Writing – positive aspects – can be private and provide an alternative for expressing feelings. Negative aspects – lack of member-to-member interaction, members could become more withdrawn, time constraints. Movement – positive aspect – tend to be energizing. Negative aspect – can increase members’ self-consciousness.

Impact on individuals. From what is known about this group’s members, there should not be any negative impacts and the positive outcomes for individuals could promote their progress.

34 Procedures and Process for Use of Creative Activities

5

6 7

8

Benefits for the group: as a whole. Members can be taught how to express feelings and encouraged to express these through use of a creative activity, members will become actively engaged in creating a product, energy is introduced, and the group can move forward. Members’ abilities: ability to participate. This was noted earlier in the description of the group. All members have the capacity to participate. Group factors: the group seems to have moved beyond the beginning stage so that many creative activities could be less threatening. Thus, it is likely that sufficient trust and safety have been established so that members can trust the group leader to protect them, and this will increase their willingness to participate. The group leader has to describe the proposed activity, provide a rationale, solicit members’ cooperation, and be willing to not use the activity if members request to not participate. All ethical considerations must be met. Tentative selection: by this time, you have narrowed your choices to a very few, or to one. If you still have more than one possible activity, review both for suitability for your group. Each group has its own unique set of characteristics, and you can now select one that seems to best fit the group and its need at this time.

Questions for Exploring and Expansion Develop a set of three to four questions you could pose that would keep the activity focused on the goal and purpose, and that would guide members’ personal exploration of their experiences and/or outcomes. General questions that are almost always appropriate are as follows. These are in addition to the focused ones.






What feelings, thoughts or ideas emerged as you completed the activity? What feelings are you experiencing as you talk about the activity? What associations to your current or past life can you identify? Was any part of the activity a surprise or troubling for you? How would you summarize this experience for yourself?

The use of the described creative activities relies on the group member’s personal understanding and associations, and does not expect that the leader and other group members have special knowledge that would provide an interpretation that the member must accept. In other words, the leader does not interpret the symbols for members, but rather allows the individual member to suggest their own interpretations, associations, and meanings. The assumptions that guide this perspective to allow members to make their own associations or interpretations are as follows:

Procedures and Process for Use of Creative Activities









35

Symbols will have personal meanings and associations for members and it is unlikely that others can know what these are. Group members will be more open and accepting and less defensive when they can make their own interpretations. It is much less threatening to the person when personal associations are accepted as valid. The understandings can emerge in a form that the person finds useful and accurate. Members will feel more in charge of their own self-disclosure. Shame and guilt feelings can become more manageable for the group and its members.

Materials and Supplies If creative activities are used in a group, it is helpful to have appropriate and sufficient materials readily available. Each activity in this book has a list of needed materials and it may be helpful to have a “toolbox” of materials always available. Suggested materials for a toolbox, or to always have available include the following: 1

2 3

4

5 6 7

A variety of paper in several sizes such as newsprint, copy paper, and construction paper. The paper does not have to be expensive, but should be available in sufficient amounts. Glue sticks or paper glue. A set of crayons, or colored pencils, or felt markers for each group member. When you compile your toolbox you may not know how many members are in the group, and it is suggested that you plan for at least ten members. Scissors for each member if group members are able to use these. Some group members may have difficulty using scissors, or it may not be advisable to let them have scissors, and in these cases, the group leader needs to adjust the activity to eliminate their use. However, if it is appropriate and the activity calls for their use, try to have at least one pair of scissors for every two group members. Unlined index cards in a variety of sizes. These can be used instead of paper for some activities, and are sturdy for drawing and pasting. Masking tape for posting directions and/or products. Collect a variety of catalogues and magazines that can be used for images and collage.

Once you have selected the kind of activity, or the specific activities you intend to use, the next task is to gather needed materials, such as paper and glue. Try to have sufficient materials so that each person has a separate set. The activities presented in this book call for relatively inexpensive materials so

36 Procedures and Process for Use of Creative Activities

that having separate sets for group members should not be overly expensive. The only kind of activity presented here that would be the exception to the group leader’s supplying the materials is for scrapbooks. These are so personal that it is probably best to have group members secure these for themselves. If cost is a concern for group members, there are alternatives presented in the discussion on using scrapbooks. Generation of a Formal Plan for Implementation A formal plan for implementation can begin now that you have an activity to use. Up to now the planning has been primarily cognitive that is, thinking about what to do. It could be helpful to write an outline for the information such as the following. Example Formal Plan Activity: Emotions Goal and objectives: To energize the group, and to provide a means for expressing difficult feelings. Materials: A set of crayons, or felt markers, or colored pencils for each participant, and sheets of paper for drawing. Procedure: 1. Introduction 3 minutes (more time may be needed if there are numerous questions) 2. Distribution of materials 2 minutes 3. Instructions and production 10 minutes (Read these one at a time allowing time to finish the symbol before moving to the next one)

a b c d

Select one color and draw a Select one color and draw a Select one color and draw a Select one color and draw (peaceful).

4. Reporting and expansion – (sharing products) 5. Enhancement

symbol for happy. symbol for sad. symbol for frustrated. a symbol for contented

10 minutes 15 minutes

Explore the following questions:







What personal associations, thoughts, and feelings emerged as you completed the activity? Which symbol was easiest to think of, and draw? Which was most difficult? What similarities do you see among group members? Differences? What is the most intense or focal feeling for you now?

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37

6. Review and evaluation Take time to mentally review the session and reflect on what went well, what did not go as planned or presented difficulties, what needs to be changed, and if the goal and objectives were accomplished. It can be helpful to reflect on what emerged for the group and its members as material for further consideration and exploration. Some activities can be very meaningful for some group members, they will continue to reflect and explore their personal material, and this can reemerge in future sessions.

The Process for Implementation Phase Now that the plan is complete, the process to introduce the activity is described, including how and what to observe as members work, handling questions, and providing encouragement. Introduction of activity It is very important to introduce the activity in a way that allows members to assess their personal psychological risk(s) and make an informed choice about participation. It is also ethically responsible to give members the option to not participate and, if even one member objects, it is best to relinquish the plan for the activity and to use that time to explore the resistance. The group does not benefit when one or more members are openly resistant about completing an activity. There is probably a shared reason for the resistance that could be a reflection of unspoken resistance from other members. Do not force or push an activity. Take that time to try to better understand what the resistance is about, such as the following usual or common possibilities:







Fear of unleashing uncontrollable conflict Fear of intimacy Fear of finding out something about oneself that could be upsetting A disguised way of challenging the leader Feelings of danger in the group such as an unidentified narcissist, borderline, or quietly explosive member (Brown, 2007) An unrevealed urgent and important problem someone is experiencing

There are numerous valid reasons for the resistance, and these should be respected. Let’s assume that group members are cooperative and are willing to try the activity. Don’t skimp on the information provided in the introduction, but don’t overly explain either. Too much information could affect spontaneity and creativity. Members may be inclined to want to give you what they think

38 Procedures and Process for Use of Creative Activities

you expect, instead of their personal experiencing, when you overexplain. Introduce the activity with an explanation of the general purpose, what members will be asked to do such as draw or write, and an overview of what to expect will emerge for them such as feelings. Stay vague and general for the last item as you don’t want to direct their personal experience. Give them the option to stop participating at any time during the activity if they should become upset, or feel overwhelmed. Note: if a member should stop participating after beginning the activity, it would be helpful to guide their understanding what was emerging, and what was producing the upset or feelings of being overwhelmed. A sample script for an introduction follows. The script is based on a perceived group constraint around expressing feelings. Sample Introduction of Activity Script Some group members have identified one of their relationship difficulties as an inability to express feelings, and all members seem to agree that it is difficult or impossible for them to express negative thoughts and feelings (Problem identified). I would like to try an activity that could begin to help make it easier to express all types of feelings, and I need your permission to continue (Giving members control). The activity consists of having you think of symbols for four emotions I’ll name one at a time, then select a color that you related or associate with the symbol, and draw the symbol on a card. We’ll then talk about the symbols and their associations for you. (Description of the procedure) You can stop at any point along the way if you choose. (Permission to opt out) Are there any questions? (Pause and answer questions) Does anyone object to doing this activity? (This is where objections and resistance could be explored) Are we ready to begin? (One last chance to opt out). Observing Members As They Work Important information can be gained through observing the individual group members as the activity is introduced and as they work. Notice their facial expressions, body postures, the pace at which they work to complete the activity, pauses, and the need for clarification. Walk around while they are working to get the best angles for observing each member, and at different points during the activity. Facial expressions can signal distress, confusion, impatience, delight, and involvement, and other such feelings that can arise during an activity. Don’t do anything unless it seems as if the member is becoming flooded and/or overwhelmed with negative emotions. If this should occur, go to that member and quietly ask if you can help as you noticed their distress. Give the member permission to stop participating at this point, and ask if they will be willing to talk about their experiencing during the reporting phase.

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39

Body postures, like facial expressions can also provide clues. Look for tense body positions; if the member is protective or hiding their product, such as an arm positioned as if they were shielding their product; legs moving restlessly or entwined tightly; or other postures that signal excitement, pleasure, and so on. Notice the pace used by each member when working. Do they work effortlessly at a quick or measured pace, or are there starts and stops? Do they seem decisive, at a loss, pensive, and so on? Interruptions of working could signal thinking, unpleasant associations emerging, pleasant memories and associations, and other such feelings. Observing also extends to the other phases: reporting, and exploration, and expansion. Observe members and the group as a whole as there is much information that can be gathered other than the content that is verbally expressed. Group leaders can find the following observations to be helpful:








Similarities among members can be identified and remarked on even when the similarities are not readily apparent to those members. Areas of sensitivity for members can be noted for exploration in subsequent sessions but not commented on or explored in this session. Intense emotions can be observed and steps taken to reduce these before the session comes to a close. Member-to-member empathic responses can be indicative of unrevealed or unaware similarities that could be the basis for strengthening connections, and for fruitful exploration. The strength of defenses mounted against knowing sensitive information about oneself can help to understand what seems dangerous or threatening to that member. Validation of hypothesized issues, concerns, and/or unfinished business for various group members. The atmosphere and feeling tone during and about the activity.

Questions When members raise numerous questions after the introduction, that can signal resistance, a need for clarification, or uncertainty. Some members can be resistant either consciously or unconsciously and this is expressed in questions about the instructions, purpose, what the leader expects, and so on. Indeed, some may not hear the instructions and ask that they be repeated. This is one reason why it can be helpful to post the questions on a chalkboard or newsprint so that members do not have to remember what to do. Others may express their resistance by misunderstanding instructions, and later ask for clarification. Another possible reason for requests for clarification is that the instructions were not as clear as needed by the group. The group leader should note this need to revise the instructions to be clearer. There is no need to address the resistance, just note it and provide the needed answers to the questions.

40 Procedures and Process for Use of Creative Activities

Encouragement Some members may need encouragement. They may want to be perfect in what they do, e.g. write or draw, and past experiences have led them to be very insecure about their ability. The group leader can provide the needed encouragement and support by being very clear that talent and ability take a back seat to expressions, and by being very accepting of whatever is produced. The Reporting Phase Each member should have an opportunity to present and share their experience and product. The activity loses its power to promote understanding or insight when carried over to another session and much valuable information for and about the member can be lost as a result of the delay. The group leader must manage this part of the activity experience to ensure that every member speaks about their experience and product. This management of reporting can be a challenge as some members will reveal material that could be very fruitful for exploration, some members can be so excited about their experience and/or product that they want to do more self-exploration immediately, and the group leader can seize the opportunity to deepen the self-exploration and feeling experience as members could benefit from this. All these reasons are valid and enticing, but must be resisted for the moment as it is more important at this point to have enough time for every member to report. Further exploration and deepening can be accomplished during the expansion phase, which can be delayed to another session when adequate time does not remain in this session. Group leaders can note what could be returned to and explored further. Why this insistence on having every member report? It is important because of the following reasons:









Speaking about the product helps each member feel validated and that they are not being ignored, overlooked, or minimized. Old feelings around sibling rivalry are less likely to be triggered when each member has an opportunity to speak rather than having some members speak so long that there is not enough time for everyone to report. The group leader would not be perceived as playing favorites when all members can report, not just some members. If only some members report then they may think that other group members will perceive them as more worthy, or more needy. It will be more difficult for a member who had an intense feeling evoked by the activity to conceal that and the group leader will then be able to take care of that before the session ends so that the member does not leave the group with an intense feeling. It becomes easier to identify important commonalities among group members.

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41

The group leader gets a better understanding of what the experience was like for the entire group when all members report, and this provides information for the future of the group as a whole intervention. Initiate the reporting phase with clear directions about what members are supposed to do, such as the following: gather members back into the circle and tell them that this phase involves having each member briefly present their experiencing or product, and that there will be limited comments, questions or explanations at this point as it is important that everyone has an opportunity to present. Tell them that exploration such as questions will continue during the expansion phase after the reporting phase. Tell members that they are being asked to give reflective or empathic responses to each other at this time during the reporting, and to save other responses such as questions for later. The group leader should also follow these directions, but can vary when it is therapeutically needed, such as when a member becomes overwhelmed by intense emotions. That situation calls for immediate intervention, but even then, the leader should resist deepening the experience or going too far with exploration. It is probably best that the leader does not give each member a time limit for presentation, such as saying that each member has two minutes for presenting. Giving a time limit could make some members rush, or feel rushed, and they then can leave out what could be important information. What could work better is to ask members to briefly present what seems important for them to report at this time, and they can have more time later for expansion and exploration either in this session or in later sessions, and to mentally set a time limit for each presentation. This will enable the leader to restrict their tendencies to deepen the experience at this point, and to move on to the next member’s reporting. If there seems to be something urgent and important for a member when reporting, the group leader can respond empathically, and say that it will be explored after all members have reported. The same script can be followed when something is not urgent and important, but seems to be sensitive and/ or has the potential for fruitful exploration. Most activities, especially those presented in this book, are unlikely to arouse deep-seated issues or uncontrollable intense emotions, but the potential for these continue to exist, and a leader must be prepared to manage these for the therapeutic benefit of group members. The Expansion and Enhancement Phases After each member reports on personal experiencing and/or their products, the group can move to the expansion and enhancement phase where the emerged material can be explored for additional meaning and insight. This can be done verbally, or through guided writing together with verbal reporting. The previously developed list of questions can be used for both.

42 Procedures and Process for Use of Creative Activities

When verbal expansion is used, the leader and other members have an opportunity to give empathic responses, and to ask for clarification. It is recommended that the group leader sets the direction and tone for this phase by telling the group that it will be helpful to the speaker for them to give empathic responses, and to restrict questions for clarification only. This will prevent any member from facing a barrage of questions that could be potentially upsetting if they are in a sensitive state with memories, associations, and the like, that were aroused by the activity. The leader should block digressions, questions and other inappropriate comments so as to stay focused, and to allow sufficient time for exploration by this and other members. One disadvantage of verbal expansion is that members, other than the speaker, can consciously or unconsciously incorporate other member’s reactions and feelings into their responses, and thereby their responses become contaminated and not entirely focused on their own personal experiencing. Some members may be more open as a result of the activity, and this openness facilitates catching others’ feelings. The similarities of experiencing can also contribute to emotional susceptibility. Another disadvantage is that more time may be taken per member to facilitate their personal exploration so that there is not sufficient time remaining to take all group members through the process. Guiding personal expansion and enhancement through writing prevents the two disadvantages seen for verbal expansion and enhancement. Every member facilitates their own exploration. The procedure would be as follows: 1 2 3

4 5 6

After the reporting phase is completed, distribute paper and writing instruments. Ask group members to reflect on their experience and products, and to write responses to your questions. Present the questions developed during the planning phase one at a time, allowing sufficient time between questions for members to write their responses. If someone does not seem finished, tell them that they can return to the question later. Have a mentally set time frame for writing, stay on task, and move it along without wasting time. Regroup and have members report as much or as little of what they wrote as they choose. Give empathic responses, restrict questioning, and ask group members to do the same.

Additional expansion and enhancement can continue at a later time. Group members can be less resistant and defensive when they are the ones who decide what material to focus on, and this leads to more fruitful selfexploration. Group leaders can note what emerged that can be returned to at subsequent sessions, deeper and more meaningful similarities among members, and possible areas of sensitivity.

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Summary The ten principles for use of creative activities in group therapy, which form the framework and basics for those activities that are presented in this book, were described. Also presented were the general guiding assumptions for use of activities, a selection process, and the phases for constructive use of activities. Sample activities were presented as illustrations for selection, initiating, reporting, and expansion. The next chapter discusses the leader’s facilitative attributes and skills that will aid members to derive the most from their group creative activities and from the group experience.

References Brown, N. (2007). Coping with infuriating, mean, critical people. Westport, CT: Praeger. Gelso, C., & Hayes, J. (2007). Countertransference and the therapist’s inner experience: Perils and possibilities. Mahwah, NJ: Erlbaum. Yalom, I., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books.

Chapter 3

Group Leader Facilitation Attributes and Skills

Introduction This chapter presents material that addresses the most effective group leader facilitation attributes and skills, the skills for working with individuals and at the group level, and group process and process commentary that will be especially helpful when using creative activities. These are the attributes and skills that will help the group get the most out of participating in creative activities. Presented are fundamental attributes, therapeutic skills, and the development of the inner self. Attributes are the fundamental characteristics that are embedded within the individual that contribute to the therapeutic alliance. These fundamental attributes are conceptualized as empathy, the attitudes toward group members that contribute to forming the therapeutic relationship, the leader’s psychological boundary strength that will prevent them from emotional contagion, help to provide increased emotional presence in sessions, and the role of healthy adult narcissism. Building on fundamental attributes are the therapeutic skills for individuals and at the group level. They are skills that can be taught and learned. Examples of helpful skills that are presented are empathic responding, identification of empathic failures and how to repair these, process and process commentary, and coping with resistance and transference. The final major topic presented is developing an inner therapeutic self for the group leader so as to facilitate the growth and development of group members through the use of a self-reflective stance. This is how a group leader can examine their thoughts about self and about others, monitor countertransference that had the potential for harm, understand the feelings that emerge during group sessions, and make suggestions for differentiating between self-reflection and self-absorption.

Fundamental Attributes The basic relationship attributes that are critical for group leaders are empathy, an emotional presence, genuineness, positive regard, tolerance, nonjudgmental, DOI: 10.4324/9781003251989-3

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psychological boundary strength, and development of healthy adult narcissism. These are the inner attitudes and self-understanding that lead to behaviors that will help build the therapeutic alliance, allow for effective interventions, and reduce the likelihood of therapeutic ruptures. Many people seem to consider empathy and sympathy as the same when they describe the two, or when they describe their experiencing. Empathy is defined as entering the world of the other person, sensing or feeling what they are feeling without losing the sense of yourself as separate and distinct (Rogers, 1951). Being empathic does not mean that you lose your sense of yourself as separate and distinct from the other person. Central to the attributes for group leaders is the ability to have an emotional presence in group sessions. This means that the leader is fully present in the here and now and their focus is on the group and what the group members and the group as a whole are experiencing. This emotional presence permits the group leader to tune in to the group’s process, to have a better understanding of what group members are feeling and experiencing, to observe group dynamics, and to sense the cues for when interventions are needed. Attitudes for developing the therapeutic relationship include authenticity, caring, positive regard, and tolerance. Being real and authentic in your attitudes and behaviors is important to build trust between the leader and members and encourages their disclosures about very shameful and painful personal information. The leader can also increase feelings of trust and safety by making members feel cared for and that they are held in positive regard. Group members must develop feelings of safety and trust in the leader and group before they can conquer their fears enough to allow themselves to talk about sensitive issues and concerns. What a leader does and says is critical to providing a group atmosphere to encourage self-disclosure and overcome fears. Tolerance and being nonjudgmental as basic attributes mean that the group leader is able to tolerate differing opinions, ideas, and even values. This can encourage the expression of members’ thoughts, feelings, and ideas without fear of being perceived as wrong, weird, or unacceptable. That does not mean that the leader has to agree with members, just that they do not evaluate them. Psychological boundary strength refers to the level and extent to which the person has achieved separation and individuation so as to be in control of what they let into themselves, and what they are able to screen out. This understanding helps to prevent emotional contagion, incorporation of projective identification, and allows empathy consistent with the definition where the inner world of the other is sensed without becoming overwhelmed or enmeshed. Strong and resilient boundaries (Brown, 2018) allow the group leader to feel what the member is feeling without incorporating that feeling into their self and being unable to relinquish the feelings. This extent of psychological boundary strength is particularly helpful when facilitating groups where members can have intense negative feelings and, can also prevent the group leader from becoming emotionally exhausted from group sessions.

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Development of healthy adult narcissism (HAN) not only allows the group leader to have the most positive and constructive therapeutic relating attributes, in addition it can also prevent the leader from actions that can be harmful to group members. HAN is defined by Kohut (1977), Stolorow (1986), and Brown (1998, 2011, 2021) as having empathy, wisdom, creativity, and an appropriate sense of humor. This perception of HAN conceives of narcissism as self-esteem and as developing throughout life on a continuum. An example of leader self-absorption is their thought and feelings similar to the following: “Am I doing it right?” and “Do they (group members) like me?”

Therapeutic Skills Therapeutic skills include both the individual and group levels. What is presented here is not the entire list of therapeutic skills, but these are considered to be fundamental and basic. Presented are empathic responding, empathic failures and their repair, process commentary, coping with resistance, transference and countertransference, conflict resolution, blocking, linking, and constructive use of questions. It is helpful to respond empathically as much as possible especially when using creative activities as these tend to evoke emotions. Group leaders will find it helpful to increase their capacity to empathically respond as this includes listening carefully for underlying meanings that group members may be experiencing. Basic to therapeutic listening is to reserve judgment about what the person is saying, to not become defensive or resistant and, at the same time stay in touch with what feelings are internally emerging. It is also important to not interrupt or finish thoughts for the speaker, and to not disconnect, minimize, or ignore the emotionally laden content as this carries the most important part of the communication from the speaker. There may be levels of empathic responding that could be used since it is not realistic to expect group leaders to be fully empathic with everyone all of the time. There are times when reflection of the feelings and content may be sufficient or the use of moderate or connected empathic responding. Moderate empathy is a short period of entering the other’s world that is just long enough so that their feelings are sensed and somewhat felt while connected empathy occurs when the duration of being connected to the other person’s feelings is longer than it is with moderate empathy. Empathic failures are common and are not always recognized as such (Brown, 2021; Kohut, 1977). Some indices of empathic failure include a member not receiving a response to an emotionally laden disclosure, an abrupt change of topic, content was the focus for responses with no attention or reflection provided for the emotional content, what a member said was treated as trivial or unimportant, emotionally laden content was ignored in the response, or when the speaker’s communication was used to tell another member’s story. While it is best to be able to identify and repair an empathic failure in the session

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where it occurred, it can also be helpful to repair it later. For example, when reflecting on the session it becomes apparent that there was an empathic failure. A repair begins with identifying what was considered to be an empathic failure and in the next group session to complete the repair. The results for trying to repair an empathic failure will vary. Some members can deny that they felt empathically failed, some can respond that since they were empathically failed, they assumed that what they were saying wasn’t important, and some may not even remember what happened. Some members may attempt to minimize their concerns by saying that what they were talking about was trivial. However, there are group members for whom it will be a huge relief to finally know they were heard, with the added outcome that other group members will feel that they too will be heard in the future. Group process refers to the relationships being expressed in the group in the here and now (Brown, 2003). The relationship may be between individuals, between subgroups, or between the group and the leader and the focus for using process relies on here and now interactions. The focus and emphasis are on what is taking place in the group at the present time, not why. Highlighting process tends to promote understanding for both personal individual issues, and for group issues. Yalom and Leszcz (2021) note that behavior and relationships in the group mirror those that the members have outside of the group, so observing how members interact and relate in the group in the here and now provides important clues to those behaviors and relationships outside of the group. Further, Chapman (1971) proposes that “personality consists of the relatively long-term ways in which a person engages in interpersonal relationships” and, “can be studied, understood and sometimes changed only in the context of interpersonal relationships”. Process commentary focuses on what is happening between group members, or what is being done by the group as a whole. Some unconscious, nonconscious, and unspoken relationships between members that can form the basis for process commentary are seeking connections, attempts to dominate or control, soliciting support or approval, feeling or fearing rejection, demonstrating a strong need to take care of others, and other such actions/inactions. Group level process observes and identifies when the group as a whole seems to be avoiding intimacy, or ignoring or suppressing conflict, yearning for safety and trust, wanting the leader to take care of them, and the like. Some unspoken needs or desires for the group as a whole are resistance, aggression, fear of engulfment, fear of exclusion, depression, clarification of norms, feelings of helplessness, or fear of destruction. Once the group’s needs are identified, this forms the basis for process commentary. Since the primary responsibility for process commentary lies with the leader, there are certain tasks and skills that the leader must develop and use if their commentary is to be helpful. These tasks and skills include assuming a present-centered focus, having an ability to function as the container for the group’s most uncomfortable feelings, such as fear or rage, understanding group

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dynamics as they unfold and are exhibited in the session, and being judicious about when and how to make group process commentary. Tuning into process requires a present-centered focus for the group leader to identify what the group is doing or not doing and how this is affecting the group. This requires the emotional presence of the group leader and their understanding of what the unspoken issues, needs, and concerns of the group may be at that time. Part of this tuning in can be the group leader’s ability to function as a container for the group members’ uncomfortable and sometimes intense feelings which can allow the group leader to identify those unspoken feelings that are clues to what is important for the group and its members. An understanding of the group dynamics such as resistance and the session theme also provides information for understanding the process and for making group process commentary. It is important that the group leader remains aware that even when members become accepting of process commentary, it should be provided judiciously and in a way that the group can be accepting of it. Group level interventions process comments can be very helpful and are able to address individual members’ concerns as well as the group-as-a-whole issues. Transference and Countertransference Like resistance, transference (members) and countertransference (leader) are usually present in the group. Since these tend to be unconscious or nonconscious, it is unlikely that members are aware of when this happens. Leaders are advised to continually monitor the possibility of their subjective countertransference which can be harmful at times to and for others, but to also stay aware of their objective countertransference as it can be reflective of what group members are experiencing. Some indices of possible transference and subjective countertransference are as follows:






Liking or disliking a group member Have negative reactions to a member’s input Perceiving a member’s input as positive Agreement or disagreement with a group member Forging a strong emotional connection with one or more group members

It is not helpful for the group leader to label a member’s behavior or reaction as transference as that is likely to evoke defensiveness. Group leaders can note it or consider that it is a possibility, but it is best to wait for a more obvious opening before pursuing the associations or connections to past or family relationships. Therapeutic Responding or Communication Competencies Therapeutic responding or communication competencies are divided into two categories: basic and fundamental skills used in individual and group

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counseling, and skills that have a particular application to group leadership. Basic competencies include active listening and responding, a focus on personal experiencing of members, encouraging direct responses among members, redirecting, and reframing. Basic Competencies It is essential that group leaders hone their listening skills as the ability to hear what is said, what is meant, and understand the underlying feelings is crucial to helping group members. Listening in a group setting is considerably more difficult than in an individual session as the interactions are faster and more complex (Rutan, 1993). Responding includes reflection, paraphrasing, and empathic responding. There are times when it is helpful to reflect or paraphrase what the person said so as to clarify that what was heard was what the speaker meant. Empathic responding includes verbalizing both the feelings and the content. A focus on the personal experiencing of group members especially in the here and now is a skill that will pay dividends for the members and for developing group cohesion. Although it is also appropriate to bring past and outside the group concerns, problems, and issues to the session(s), these are more effectively explored when they are brought into the present and the focus is on the member’s present experiencing. Their feelings and thoughts in the present allow them to better understand their issues, problems, and/or concerns. Directness is a skill that the leader can model, and many members will likely follow the leader’s example which is an asset to the group’s interactions as well as for their communications outside of the group. It is helpful to respond directly and specifically to what the speaker says and not to go off on a tangent with the response. Helpful ways to respond directly include paraphrasing, reflecting, verbalizing agreement or disagreement, or by acknowledging the speaker’s perspective. Other means of being direct that the group leader can model are for the leader to openly express their important feelings as these are experienced during the interactions, and by giving constructive feedback to speakers. Reframing and redirecting are also termed relabeling by Weakland et al., 1974; positive connotation by Selvini-Palazzoli et al. (1974) and noted as a positive group leadership skill by Agazarian (1997). Reframing occurs by paraphrasing what the group member said and giving it another perspective that does not change what the person said. For example, if the member noted that conflict was upsetting and that they could never be comfortable with it, a reframe could be saying that they want their relationships to be harmonious. Reframing is most useful when the speaker’s statements could use another perspective. Examples include when the speaker is focused on their or other’s deficiencies, weaknesses or mistakes; they do not seem to be aware of the positive aspects of the situation or of their effectiveness, or personal strengths.

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In addition, reframing is helpful when the speaker has a negative perspective, such as hopelessness, and reframing to provide another perspective could show them how to become more hopeful. Redirecting asks the speaker to look at other parts or aspects of the issue, problem or concern that they may have overlooked, ignored or do not even have an awareness that these exist or are possible. Redirecting is similar in some ways to reframing except that the person is guided to consider the issue, problem or concern from another direction. Reframing is particularly effective when used at the group level to illustrate to the group that there are other aspects and perceptions. Advanced Group Level Skills The next set of skills and interventions discussed are usually learned and can be challenging to develop as some are not consistent with what was learned as social convention behaviors. Social convention behaviors such as not interrupting the speaker, that others should be soothed, and that others should always be encouraged and supported. The skills discussed in this section are encouraging and supporting, blocking, appropriate questioning, and use of metaphors. An example of how metaphors could be used is also provided. These are challenging because there are no hard and fast rules for when these are needed or how to ensure that they are effective. Group leaders can be very helpful when they provide encouragement and support as many members are appreciative and may not have received this elsewhere in their lives. The other side of this is that the encouragement and support may be a hidden attempt to soothe the member(s) so that they do not experience negative feelings that would be helpful for them to explore in the group or may be given prior to understanding the situation in its entirety, or for other reasons that do not help the members or the group. There is an art to knowing when this would be helpful. For example, the leader’s encouragement and support can be especially helpful during the beginning stages of group as group members are anxious in the ambiguous and uncertain group environment but is less helpful when the group is in the third or working group stage where members work to explore difficult topics and feelings. The use of encouragement and support is less helpful when they are used to soothe members or when it could promote dependency that the group leader will rescue them from experiencing, and other possible depression of personal exploration and learning. Blocking is used when there is a need to protect group members such as when a member is being attacked or the group is moving away from an important topic, or when the emotional intensity is too high for the group to constructively manage it. Blocking is especially useful when there is monopolizing and story-telling in the group that is constant over several sessions. An example of how blocking can be used that will take into account the speaker and the group is when the leader interrupts the speaker to say that

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they want to stop the speaker and then identifies the rationale for the interruption such as, saying that they noticed that one member seems in danger of becoming scapegoated. The leader can then go on to say that it would be more helpful if group members would report on their thoughts and feelings about the impact of that member’s behavior on them rather than trying to tell the member what they want changed. Appropriate questioning is another term for probing, and knowing when and how to use questions is a therapeutic skill. Questioning is considered appropriate when the group member does not feel attacked or become defensive, there is a therapeutic rationale for the question such as clarification, and when questions are not rhetorical. It can be important to learn when not to ask questions and that it is more helpful to make statements. Brown (1998) lists three basic uses for questioning: to obtain data and information; to clarify misunderstandings; and to pinpoint something to take immediate action. Using questions as a means of showing interest is not appropriate as this can put others on the defensive. It is especially important that the group leader should be careful not to ask numerous questions and, to refrain from focusing on a member and pelting them with questions. Further, much information sought by asking questions is not necessary or relevant to either accomplishing the task or developing relationships in the group. Trotzer (1989) notes that most questions are statements that signal what the speaker wants, especially questions that are used as probes to guide the receiver to areas the speaker feels are important. Metaphors can be the abstract and ambiguous ways that the group is expressing its issues, problems, and/or concerns and it is an advanced group level skill to be able to use them to understand and make group process commentary. The metaphors that emerge in the session are how the group is talking about itself. Metaphors are things such as images, that are valid in and of themselves, but that also stand for something else. Metaphors in group sessions are being used as a nonconscious or unconscious way to express the issues and relationships in the group. Members can find it easier to express their thoughts and feelings about the group and its members by using metaphors because the real topic is too sensitive to talk about directly, or the topic is both urgent and important. Whatever the group considers to be important for the group is being expressed in metaphorical terms in the present. The group leader uses the metaphor to better understand its relationship to the group, and how the metaphor is being used by members. These metaphors can be couched in terms that are realistic or, most often are expressed in vague, abstract terms that tend to use or evoke vivid imagery or feeling. There may be the presence or absence of significant affect when the metaphor emerges and is being talked about, and although one member may express the metaphor, its expression speaks both for the individual and for the group. Metaphors tend to emerge when the group is struggling, or is at an impasse, or when members are resisting awareness of significant material, or fearful of

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overwhelming affect, unaware of real issues, and the like, and the metaphor is needed in order to express what is happening in and to the group. The next section for the chapter presents the discussion on group dynamics, group stages, and therapeutic factors.

Group Factors There are certain group factors that are fundamental to understanding how and when to intervene in group dilemmas, and are basic to the success of the group. These factors include group dynamics, stages of group development, therapeutic group factors, ethics, and cultural and diversity concerns. These are the factors discussed in this chapter. Group Dynamics Group leaders can obtain many clues about the group and its members from observing the dynamics of the group. These constantly changing factors are signals about current experiencing for individual members, and for the group as a whole. The observant group leader takes information, analyzes and synthesizes it, ensures its validity from self-contamination of countertransference and projection, and then uses this to decide on an appropriate intervention. This is a process that can be used with individual group members, and with the group as a whole. First, let’s define and describe the group dynamics that are the sources of information. Group dynamics is both a field of study and group processes according to Forsyth (1999), but Lewin (1951) defined group dynamics as the powerful processes that take place in the group. Johnson and Johnson (2006) note that the field of group dynamics is a “twentieth-century, North American development” (p. 35) that had its beginnings from many fields and has evolved into an interdisciplinary field. Contemporary emphases for group dynamics focus on the continuous movement and progression of the group, and on the interacting forces that impact the group and its functioning (Brown, 2008). As more became known about group dynamics and its complexities, more studies were conducted that produced greater understanding of the helping and restraining forces that comprise the dynamics. Studies included leadership patterns (Lewin, Lippitt, & White, 1939) group decision-making processes response patterns and roles (Bales 1950, 1953), sequential stage theory (Moreland & Levine, 1988), basic themes (Bion, 1961), norms (Sherif, 1936), interaction of personal and environmental factors (Lewin, 1951), communication and cohesion (Thibout & Kelley, 1959), motives and goals (Zander, 1971/1996), conflict (Deutch, 1949), interpersonal attraction (Newcomb, 1963), and communication networks (Shaw, 1964). Much of the early focus was on the various components and aspects of the group, but as more of the complexities emerged, more attention was given to the interactions of the

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various dynamics, the importance of group process, and a focus on the group as a whole. The idea of the group as a whole became more prominent through the work of Bion (1961) who applied psychoanalytic theory to groups, and this work added greatly to the understanding of how the whole group functioned. Bion (1961) proposed three basic assumptions for groups; dependency where members feel helpless and look to the leader for support, fight/flight where the group feels in danger and uses one of these actions as a response, and pairing where members have hopeful fantasies of being saved and of the group being constructive. Observation and understanding of the group’s dynamics reveal the current process for the group, and the identification and understanding of these dynamics allow the group leader to better intervene, and to help the group accomplish its task. The basic group dynamics to observe include: level of participation, communication patterns, feelings expressed, resistance and defenses, and how conflict is managed.










Level of participation includes the characteristic interaction and changes in interactions, input, and responses for individual members and for the group as a whole. Communication patterns include both verbal and nonverbal communication. The verbal communication patterns can demonstrate inclusion or exclusion, deference, where the perceived power and influence rests, group norms, and current emotional state. Nonverbal behavior is the major and most important part of communication, and is valuable information about what the group and its members are experiencing at a deep level. Behaviors such as, voice tone, body positioning, facial expression, body movements or lack of movement, and clusters of gestures all convey deep and important messages about current emotional states for both individual members and for the group as a whole. Feelings expressed can be an important indicator of overt or hidden issues in the group, as well as indicators for individual members’ emotional state, sensitivities, and resistance. Hidden, disguised, and suppressed feelings are important and significant for group members and for the group as a whole. Resistance is an indicator of sensitive material that is threatening and thus, must be defended against, suppressed, or repressed. Acts mobilized as defenses include denial, deflection, intellectualization, and displacement. Conflict can be revealing of the group’s fear, need or wishes, and the most important signal is how the group manages conflict. Common group conflict management strategies are denial, suppression, ignoring, and working to resolve them.

Stages of Group Development There are certain expected member behaviors that usually occur during the group’s development, and these are associated with the stage or level of

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growth that has occurred for the group. Different theorists and authors may use different terms for these stages, but the descriptions for members’ behaviors and needs have considerable similarities. Tuckman (1965) was among the first to propose and document developmental sequences for groups, and this later became known as group stages. These stages are not separate, distinct or clear cut, but almost all types of groups seem to move through some sequence of development. The literature shows several ways to categorize these stages: Forming, Storming, Norming, and Performing (Tuckman, 1965); Engagement, Differentiate, Individuation, Intimacy, Mutuality, and Termination (MacKenzie, 1990); Orientation, Conflict, Cohesion, Stability, and Termination (Yalom, 1995); Formation, Conflict, Rebellion, and Termination (Weber, 2006), Formative, Reactive, Mature, and Termination (Rutan & Stone, 2001). All categorizations include the four stages that are used for this discussion: Beginning, Conflict, Cohesion, and Termination. The group’s stage of development can be a rich source of information about what members’ needs are at a particular time, can suggest interventions, and can provide clues for difficulties, challenges and dilemmas that may emerge. This information may be of particular importance for adult therapy groups who are likely to have sufficient time available to experience all the group stages. Stage 1 – Beginning Stage 1 behaviors are reflective of the behaviors and internal states many group members can experience in new situations where there is ambiguity and uncertainty. Members are usually anxious about acceptance-rejection, the ability of the group to meet their needs, the competence of the group leader to care for them and to guide their changes, what is expected of them, and what will be their role (s) in the group. Their past experiences with relationships and authority figures also factor into their behavior, fears, and expectations. Group leaders must stay aware of the anxiety that the first stage of the group engenders in the group members, and focus on establishing trust and safety so that the group becomes a safe place for members’ disclosure, self-exploration, and for contributing to each other’s growth and development. Creative activities can be very helpful to address all of these concerns.



Openly address members’ fears and concerns which will mainly focus on how they will be cared for in the group, whether they can be helped, and symptom relief. Identify and highlight similarities among members. Groups become cohesive around shared similarities and fail to become cohesive because of perceived differences making it essential that the group leader focus on similarities in the first stage of group development. Creative activities can be used to identify major and covert similarities among group members.

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Collaboratively set goals with group members. While the organization of the group may have a stated goal such as coping with substance abuse, it is likely that each group member has a different definition of what this will mean for them. Collaboratively setting goals allows members to identify the common goals among them as well as their unique individual goals. This allows the group leader to direct the group to accomplish the agreed-on goal(s). Seek out members’ strengths to build on, as this is much more constructive than trying to remediate deficiencies. In building on strengths, the challenges and/or weaknesses are also worked on but the encouragement to continue to work comes from identifying and emphasizing their strengths. Provide symptom relief where possible. No general statement covers all of the symptoms that members will bring to the group. But the group leader should understand that symptom relief is most often sought so that members can feel hopeful that they will be helped. Many members will be seeking to feel better about themselves, that they can be adequate, and that the group will be helpful. Foster an atmosphere of inclusion in order that group members feel the group is safe, that they will not be rejected, and differences will be tolerated. It doesn’t much matter what these differences are; the group’s climate should be one of tolerating but not necessarily agreeing with differences of opinion, values, and most of all, toleration of individual differences around religion, race, ethnicity, identity, and so on. Instil realistic hope is a major group leader task. Members may be hopeful, but some do not have realistic hope for changes in that they want to change another person, have someone else be different, ignore medical or other scientific findings, and desire any number of outcomes from attending the group that are not achievable, or unlikely to be achieved. It is essential that the group leader does not foster unrealistic hope. Model empathic responding will be very helpful to group members to help improve their interpersonal relationships both in the group and outside the group in their other relationships.

Stage 2 – Conflict Stage 2 is generally characterized by dissention, discord, and disagreements. Group members are now starting to assert their independence and, just as toddlers do, they want to both hold on for safety and to let go to explore, but don’t quite know how to get both needs met at the same time. They lash out in confusion and frustration, displacing their conflicting needs on others. These are some of the reasons why this group stage is so uncomfortable and can pose difficulties for members and the leader. Members challenge each other and the leader to be both dependent and independent at the same time.

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Group leaders have to stay in touch with both sets of needs, to model how to give and receive constructive feedback to eliminate or moderate negative aspects of the behavior, teach positive confrontation or enlightenment skills, and to monitor their old unresolved parental issues that could emerge as countertransference. The group leader’s self and skills are very important for the successful transition of this stage as how the leader reacts to challenges from members shows them how the leader perceives them and their roles. When the leader is not defensive and responds in a positive way, members learn how to be constructive when expressing disagreements, how to use the information from the disagreement to strengthen relationships and not allow the disagreement to be destructive, and guides members to learn new ways of understanding their reactions and feelings, and new ways to relate and behave. This is a very busy and potentially rich stage even with all of the discomfort. Dilemmas and difficulties during stage 2 generally arise around conflict and fears of being destroyed because of it. Some members fear conflict so much because of their past experiences that they work hard to suppress any hint of conflict. By far the most difficult situation that usually occurs in stage 2 is when the leader is challenged or attacked. This challenge can come from one or two members, but the challenge also expresses something about what other members are thinking and feeling. How the group leader reacts during these challenges plays the most important role in determining the success of the journey through this stage. The main group leader tasks during this stage include the following:







Monitoring self-reactions and possible countertransference to prevent defensiveness and/or reactive aggressiveness Model giving constructive feedback Intervene to prevent member to member attacks and other forms of aggression Demonstrate and teach conflict resolution that can strengthen relationships rather than destroying them Use opportunities to provide the corrective emotional experience Accept catharsis but provide guidance to foster intrapersonal and interpersonal learning so that it does not remain as just emotional venting

Stage 3 – Cohesion Often the cohesion stage, this level of group development, can be very productive for group members. Sufficient trust and safety have been developed so many of the fears around self-disclosure, acceptance, and positive regard are answered and are of lesser concern. Time and experiences in the group have fostered positive connections, the emergence of many group therapeutic factors, and it is much less scary and threatening to engage in self-exploration of long-standing issues and concerns. There is a spirit of cooperation, support, and hope in the

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group. Members can be more confident in their self-efficacy, and more willing to engage in personal risk-taking for disclosure and exploration of issues. There is a deep intimacy for the group. The group leader is less active during this stage, letting members be more independent and interactive with each other. Members become willing to explore sensitive issues, support and encourage each other, and considerable therapeutic work is done. Sessions are harmonious; members derive enjoyment and growth and are able to take charge of much of their development at this point. There are two likely situations that need group leader interventions; when the group starts to value harmony to the point where feelings are suppressed and members are reluctant or avoid confronting each other, and when the group engages in “group think” where no differences among members for values, perspectives, opinions, and the like are tolerated. While the feelings that harmony produces in the group are comforting and supportive, too much harmony stifles expression and growth. Group leaders must stay aware of these possibilities. Stage 4 – Termination Most groups have a beginning and ending stage, and the ending stage should be a part of the planning done in advance of the group’s beginning (Brown, 2007). The exception for this stage is continuing groups where members may terminate, but the group itself does not end. In this case, the planned closure should be for the terminating member, and for the remaining members who will continue but in a different group because a member has left the group. Stage 4 member behaviors include some regression to behaviors from earlier stages. The potential loss of the established security, connections, and support can be frightening to some group members, and they can fear being destroyed without the resources to lean on that the group and leader provide. Some groups may even produce dilemmas in the effort to prevent the group from ending. Expected member behaviors can include panic, withdrawal, sadness, and devaluing of the group experience as defenses against feeling the loss of the group. The major leader tasks are to prepare members for separation, and to become independent and this process should begin about halfway through the duration of the group. Preparation includes reminding members of the time boundary, highlighting progress and growth, reviewing personal goals and accomplishments, and affirming members’ strengths. It could be helpful for some members to verbalize their fears so as to assess their realism and validity. The group’s ending is a threshold or boundary, just as encountered in fairy tales. There will be change, the future is uncertain, and there is concern about one’s ability to cope.

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Cultural and Diversity Sensitivity It can be extremely important for the group leader to have an understanding of the need for cultural sensitivity. Culture is a significant influence on everyone’s development, and many of its lessons are integrated into the person and acted on unconsciously. In addition, there are different cultures, each with unique characteristics and expectations that were internalized and are now an unconscious component for the various group members. (Brinson & Fisher, 1999; Chen & Han, 2001; Colmant & Merta, 1999; Haley-Banez & Walden, 1999; Kim, Omizo, & D’andrea, 1998; Santiago-Rivera et al., 2002; Sue & Sue, 2003; Torres-Rivera, Wilbur, Roberts-Wilbur, & Phan, 1999) Thus, group leaders cannot know all of the cultural influences for every group member, but these influences will have an impact on the interactions and functioning of the interactions with group members. Group leaders need to have a high level of cultural sensitivity and competence in order to develop the therapeutic relationship, help group members set reasonable goals, understand how ethics will be operationalized, and to build safety and trust (Abernethy, 2002). This is a difficult job even when group members are native USA citizens, and much more difficult when group members are immigrants or citizens who continue to practice many of the aspects of their culture of origin. It is not possible to provide all the information needed for developing awareness, sensitivity, and competence here as the subject is too broad for adequate coverage. Readers are encouraged to consult the many books and articles on the subject, to enroll in courses and workshops, and to consult with experts. The latter will be especially important when there are group members from varying cultures. This discussion is limited to presenting some cultural variables that can be important for many group members. Variables that can be of importance include the perceptions of authority figures, source of illnesses or other conditions, gender and gender differences in expressing emotions, the role of family, meaning attribution given to experiences, and language barriers, facility, and understanding. Authority Figures – the group leader is generally perceived as an authority figure by almost all group members. Group leaders are the holders of knowledge, the guide for information and understanding, the teacher of skills and, if a court ordered participation, the determiners or contributors to their fate. However, there can be varying reactions to group leaders as authority figures depending on group members’ reaction to authority, such as over compliance or defiance; their perceptions of your authority as moderated by the leader’s gender, age, race/ethnicity, and by their attitude toward differences. Spierings (2004) provides three perceptions about the source for the illness or condition; medical, magical, or religious. Medical refers to the western understanding that many illnesses and conditions are caused by viruses, bacteria genetics, environmental factors, and so on. They tend to look for an empirically derived cause and effect that can be replicated and generalized. There is a considerable emphasis on research and the scientific method.

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Some cultures, even some in the USA, believe that illnesses and conditions result from magical outside sources such as: the evil eye, an act of a wizard, or a curse. They believe that they can only get better and be cured if the person (usually) performing the magic can be overcome, or if they can find another source that is more powerful with greater magic. Religious sources for illnesses and conditions are seen by some as punishment for sins, failing the higher power, or as karma or fate. People can believe that they must pay the penalty for being who they are, or for what they did or did not do through their pain and suffering. The source of the condition or illness is the only one who can cure them or cause relief. Faith is a huge factor in healing as has been documented in many studies and can play a major role for many group members. The term, faith, is used here because the perceptions of the source of the illness or condition relies heavily on faith – whether that faith is in the medical and scientific professions, magic, or in religion. Group leaders with members from varying cultures may want to explore what members believe to be the source for their condition or disease. Expressing Emotions – Group leaders are encouraged to learn the cultural expectations for expression of feelings for major countries in the world as these can be contributors to how or when group members will express their feelings. In addition to cultural differences, there can be gender differences within countries/ cultures, and there can be unspoken norms about expressing certain emotions, such as shame, guilt, anger, fear, and disgust. Group leaders cannot assume that group members are resisting because of personal issues as the resistance to expressing or exploring emotions could have its basis in the culture of origin. Another part that merits attention is how feelings are or are not displayed. In some cultures, even some within the United States, people are not expected to display their feelings, and can go to great lengths to keep their nonverbal behavior from reflecting their feelings. Generally, in the USA and some other western countries, the facial expression is thought to be the prime conveyor of feelings being experienced by the person. However, this is a fallacy as people learn through their experiences that it is not always appropriate or safe to show one’s true feelings on their face. There are other cultures where subtle nonverbal behavior reveals the person’s feelings, and members of that culture become expert at reading those signs. It can be helpful to research how emotions are verbally and nonverbally expressed in the culture of origin for the group members. The Role of Family – Cultures that value collectivism (the group) over individualism can also expect that the family and its members are intertwined and that the family makes the decisions for the individual members. Thus, information is freely shared among family members, and actions taken only after consultation among them. Group members from these cultures may not consider sharing information with family members as breaching confidentiality or be able to implement an action plan prior to receiving family permission.

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Expect group members from collectivism cultures where the group leader is educating all the family of those members. Be very specific in an effort to set the limits for confidentiality for these members. For example, it can be permissible to discuss the factual material and the structure for the group sessions or group, but not discuss what individual members say and do with people outside the group, including with their family. Other things that can be shared are the group members’ personal thoughts, ideas, and feelings about themselves and their conditions or illnesses, personal action plans, and sources of information. If there are varying cultures represented in the groups, this emphasis and specificity can be extremely important for establishing trust and safety for other (all) group members. Meaning Attribution – There are three major systems for attribution of meaning for experiencing: personal responsibility, fate, and unseen forces. The USA main culture places a lot of emphasis on personal responsibility and control of what one experiences. Choices, decisions, and other personal interventions are emphasized, and people are expected to actively participate in their healing and recovery, to say nothing of active prevention actions. This expectation is at the basis of the establishment and the wide use of support and therapy-related psychoeducational groups where it is postulated and believed that these groups can help facilitate coping, change, and recovery by providing information, encouragement, and support, and by teaching specific skills. There are some cultures where illnesses and other conditions are perceived as fate or predestination. There was little or nothing the person could have done to escape this experience. This perspective is closely tied to the spiritual/ religious bias of the culture and emphasizes illnesses and conditions as punishment for not being or living in accord with those principles, either in the person’s current life, or in their former life. Group members from cultures that have this perspective are not likely to take an active role in their recovery or healing, as they can believe that they have no control or impact on what happens to them. The cultures that attribute meaning of experiences to unseen forces are those that emphasize spirits in nature or from elsewhere, ancestors, and other people who have magical powers. Group leaders cannot assume that members from a particular country or culture will have the unseen forces perspective, as beliefs vary in almost every culture. There is also a certain amount of fatalism when people believe in the power of unseen forces, and that the person caused the illness or condition by themself or their actions. The primary way for getting well would be to appease these forces, or to overcome them in some way. A group leader can ask them to describe what they feel they must do, in addition to the medical or other treatment they are receiving, to address these unseen forces. Do not ignore or dismiss this perspective as being counter to the medical/scientific one as it is important for improvement, healing, recovery, and for building trust and safety in the group that members with these beliefs have some

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acknowledgment of their perspective, and how it could be incorporated into the more traditional western medical system, and other treatments and interventions. Culturally Sensitive Group Leader Strategies There are six basic strategies that can help guide group leaders to be, and to be perceived as, more culturally sensitive and competent, become open to learning about cultural differences, limit the amount of information given at any one time, check to ensure clarity and understanding, use open questions, use simple words and reduce or eliminate jargon, ask group members for information about respectful interactions and cultural sensitivities and taboos. The discussion to this point has emphasized the need to learn about other cultures. It is helpful when the group leader demonstrates an openness to learning more about members’ culturally determined expectations. Information from consultants such as college professors from that culture or who have studied the culture, books, the internet, and other reference materials, and the members themselves can be rich resources for needed information and understanding. Limit the amount of information given at any one time because the language and concepts can be foreign and new, and because these group members may need time to mentally translate the information into their native language and then translate that understanding back to English in order to ask or answer questions. It is always helpful to have group members paraphrase or repeat instructions, information, and so on, to ensure clarity and understanding and this can be even more important when the group members are culturally different. There can be times when group leaders think they are saying one thing, but say something else, and there can be many occasions where members hear and understand something different from what was actually said. Paraphrasing and asking them to repeat what they heard, or what they thought was meant can help prevent errors and misunderstandings. Use open questions that will give group members an opportunity for exploration and elaboration. This approach also prevents being pushed in a particular direction, or to reach a predetermined conclusion or decision that reflects the group leader’s perspective rather than members’ perspective, values, and choices. Do not frame statements as questions as this can be confusing to some people. Language can be a barrier for culturally different group members, and group leaders are encouraged to refrain from using professional jargon, and to use as simple words as possible. It could be vitally important for group members’ understanding and compliance with treatment, learning coping skills, making needed changes, and so on. Conveying the information so that it is understood is of critical concern, and group leaders must pay attention to their choices for words, even if they have to use several simple words instead of one word that incorporates many complexities.

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Spierings (2004) recommends asking group members from a different culture about basic rituals that convey respect and regard. It could also be helpful to ask about cultural sensitivities and taboos. It can be helpful to specifically inquire about how to say hello and goodbye, greeting rituals and gesture, correct titles for addressing them, such as Senor, Señora or Doctor, sequence for names, as not all cultures put the family name last, the extent of eye contact that is acceptable, unacceptable nonverbal postures, gestures, and body positions, acceptable physical space or proximity, perceptions about authority figures, sensitive topics, such as religion, history, relations with the US, and politics, and how status or “face” is maintained. There are many culturally determined ways to show respect and regard and conversely, many ways to unintentionally insult or offend. Therapeutic Factors The importance of factors conducive to promoting therapeutic progress, healing and change for group members has received attention in the literature (Corsini & Rosenberg, 1955; Kivlighan & Mulligan, 1988; Colijn et al., 1991; Kivlighan & Goldfine, 1991; Crouch et al., 1994; Fuhriman & Burlingame, 1994; Yalom, 1995; MacKenzie, 1990; Dies, 1997; Fuhriman, 1997; Kivlighan et al., 2000; MacNair-Semands & Lese, 2000; Kivlighan & Holmes, 2004; Tschusckke & Dies, 1994). What has emerged from these studies and reviews is confirmation of the impact of behaviors and attitudes that are clustered as categories for therapeutic, curative, and change; some are common and valued for all types of groups, some differ in their importance and value depending on the type of population; and that there are few guidelines for leaders on how to foster and encourage the emergence of these factors. These factors have been given various titles, but can be generally categorized as Yalom (1995) presented them. These 11 factors are: universality, instillation of hope, altruism, interpersonal learning, imparting information, catharsis, corrective recapitulation of the primary family group, imitative behavior, existential factors, socializing techniques, and cohesion. Universality contributes to therapy by emphasizing commonalities among group members, reducing their feelings of alienation, of being alone in their struggles or misery, and/or that they are weird or significantly different from others in negative ways. Hope is very valuable in providing motivation to continue the struggle and provides a feeling that the struggle will pay off in meaningful ways. Hope can increase members’ self-perceptions of worth and value to others and to the universe and is inspiring. Imparting information is not advice-giving. Rather, this therapeutic factor decreases ignorance, empowers the receiver to act on their behalf, and increases solution development for problems. Interpersonal learning allows members to increase self-knowledge and self-understanding through feedback from others. This feedback provides the personal with

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information that others can see, but is usually not seen by them but could be important for relating and communicating with others as well as achieving a greater understanding of their thoughts and feelings. Existential factors are usually present in all groups although these may not be visible or prominent. The therapeutic awareness and discussion for these factors are encouraging to members as these discussions promote awareness that these issues do not have solutions (e.g. the indifference and unfairness of the universe); that all humans struggle with these issues throughout their lives; and that each person has a unique approach and resolution for these factors. Catharsis can bring relief when suppressed or repressed intense feelings are expressed and seeing that this does not destroy oneself, others or relationships. However, in order to be most effective the emotional venting must be accompanied by a greater understanding of oneself through receiving empathic responding, differing perceptions or other feedback that promotes self-understanding. Socializing techniques are very useful for almost all group members. Teaching members these techniques demonstrates how they can initiate meaningful connections to others, reduce behavior and attitudes that prevent connections, and increases awareness of others-in-the-world as separate and distinct individuals. Imitative behavior is demonstrated by both the leader and members. Members can learn and practice new and more effective ways of behaving to get needs met, develop more constructive attitudes through seeing the modeling behavior of others that is more effective than their present behavior. The corrective emotional recapitulation or reenactment of the family of origin makes a valuable contribution to therapy by providing a new perspective for old hurts, resentments, and relationships that can promote healing, forgiveness, and changes. Cohesion provides the necessary conditions for the productive or working stage of the group. This is therapeutic because the group has reached a point where members experience feelings of belonging, connectedness, and productivity; they have learned the benefits of cooperation versus individual efforts, and there are increased feelings of satisfaction with self and with others.

Summary This chapter describes the basic group facilitation skills for all groups but may be especially important for the leaders of groups who plan to use creative activities. The brief overview of group leader attributes, communication skills, process and process commentary, and developmental group stages are intended to assist group leaders in their selection of creative activities that will be helpful for group members and for the group during the various stages of group development. Also, this discussion may be helpful for group leaders in facilitating the outcomes for these activities for further personal exploration by group members.

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References Abernethy, A. (2002). The power of metaphor for exploring cultural difference in a group. Group, 26(3), 219–231. Agazarian, Y. (1997). Systems-centered therapy for groups. New York: Guilford Press. Bales, R. (1950). Interaction process analysis. Reading, MA: Addison Wesley. Bales, R. (1953). The equilibrium problem in small groups. In T. Parsons, R. Bales, & E. Shils (Eds.), Working papers in the theory of action (pp. 111–162). Glencoe, IL: Free Press. Bion, W. (1961). Experiences in groups. New York: Basic Books. Brinson, J., & Fisher, T. (1999). The Ho’oponopono groups: A conflict resolution model for school counselors. Journal for Specialists in Group Work, 24, 369–382. Brown, N. (1998). The destructive narcissistic pattern. Westport, CT: Praeger. Brown, N. (2003). Conceptualizing process. International Journal of Group Psychotherapy. 53(2), 225–243. Brown, N. (2007). Coping with infuriating, mean, critical people. Westport, CT: Praeger. Brown, N. W. (2008). The therapeutic use of fairy tales with adults in group therapy. Journal of Creativity in Mental Health, 2(4), 87–96. Brown, N. (2009). Becoming a group leader. Upper Saddle River, NJ: Pearson. Brown, N. (2018). Psychoeducational groups. (4th ed.) New York: Routledge. Brown, N. W. (2021). The significance and importance of repairing empathic failures. In Women, intersectionality, and power in group psychotherapy leadership (pp. 185–200). New York: Routledge. Chapman, T. J. (1971). The effects of using role play in a group to improve interpersonal relationships and self-esteem (Doctoral dissertation, West Georgia College). Chen, M. Y. & Han, Y. S. (2001). Cross-cultural group counseling with Asians, a stage specific interactive approach. Journal for Specialists in Group Work, 25, 369–382. Colijn, S., Hoencamp, E., Snijders, H., Van Der Spek, M., & Duivenvoorden, H. (1991). A comparison of curative factors in different types of group psychotherapy. International Journal of Group Psychotherapy, 41, 365–378. Colmant, S., & Merta, R. (1999). Using the sweat lodge ceremony as group therapy for Javajo youth. Journal for Specialists in Group Work, 24, 55–73. Corsini, T., & Rosenberg, B. (1955). Mechanisms of group psychotherapy: Process and dynamics. Journal of Abnormal and Social Psychology, 51, 406–411. Crouch, E., Block, S., & Wanlass, J. (1994). Therapeutic factors: Interpersonal and interpersonal mechanisms. In A. Fuhriman & G. Burlingame (Eds.), Handbook of group psychotherapy: An empirical and clinical synthesis. New York: Wiley. Deutch, M. (1949). A theory of cooperation and competition. Human Relations, 2, 199–231. Dies, R. R. (1997). Comments on issues raised by Slavson, Durkin, and Scheidlinger. International Journal of Group Psychotherapy, 47(2), 161–168. doi:10.1080/ 00207284.1997.11490813. Forsyth, D. (1999). Group dynamics (3rd ed.). Pacific Grove, CA: Brooks/Cole. Fuhriman, A. (1997). Comments on issues raised by Slavson, Durkin and Scheidlinger. International Journal of Group Psychotherapy, 47, 169–174. Fuhriman, A., & Burlingame, G. (Eds.) (1994). Handbook of group psychotherapy: An empirical and clinical synthesis. New York: Wiley. Haley-Banez, L., Brown, S., & Molina, B. (1999). Principles for diversity-competent group workers. Journal for Specialists in Group Work, 24, 7–14.

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Haley-Banez, L., & Walden, S. (1999). Diversity in group work: Using optimal theory to understand group process and dynamics. Journal of Specialists in Group Work. 24, 405–522. Johnson, D., & Johnson, F. (2006). Joining together (8th ed.). Boston, MA: Allyn & Bacon. Kim, B., Omizo, M., & D’andrea, M. (1998). The effects of culturally constant group counseling on the self-esteem and internal locus of control orientation among Native American adolescents. Journal for Specialists in Group Work, 23, 145–163. Kivlighan, D. Jr., Coleman, M., & Anderson, D. (2000). Process, outcome and methodology in group counseling research. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (3rd ed.), (pp. 767–796). New York: Wiley. Kivlighan, D. Jr., & Goldfine, D. C. (1991). Endorsement of therapeutic factors as a function of group development and participant interpersonal attitudes. Journal of Counseling Psychology, 38, 150–158. Kivlighan, D. Jr., & Holmes, S. (2004). The importance of therapeutic factors. In J. DeLucia-Waack, D. Gerrity, C. Kalodner, & M. Rina, (Eds.), Handbook of group counseling and psychotherapy. Thousand Oaks, CA: Sage. Kivlighan, D. Jr. & Mulligan (1988). Participant’s perception of therapeutic factors in group counseling. The role of interpersonal style and stage of group development. Small Group Behavior, 19, 452–468. Kohut, H. (1977). The restoration of the self. Madison, CT: International Universities Press. Lewin, K. (1951). Field theory in social science. New York: Harper. Lewin, K., Lippitt, R., & White, R. (1939). Conduct, knowledge, and acceptance of new values. Journal of Social Psychology, 10, 271–299. MacKenzie, K. (1990). Introduction to time-limited group therapy. Washington, DC: American Psychiatric Press. MacNair-Semands, R. R., & Lese, K. P. (2000). Interpersonal problems and the perception of therapeutic factors in group therapy. Small Group Research, 31, 158–174. Moreland, R., & Levine, J. (1988). Group dynamics over time: Development and socialization in small groups. In J. McGrath (Ed.), The social psychology of time (pp. 151–181). Newbury Park, CA: Sage. Newcomb, T. (1963). Stabilities underlying changes in interpersonal attraction. Journal of Abnormal and Social Psychology, 66, 376–386. Rogers, C. (1951). Client-centered therapy. Boston, MA: Houghton Mifflin. Rutan, S. (1993). Psychoanalytic group psychotherapy. In H. I. Kaplan & B. J. Saddock (Eds.), Comprehensive group therapy (3rd ed.), (pp. 98–150). Baltimore, MD: Williams & Wilkins. Rutan, S. & Stone, W. (2001). Psychodynamic group psychotherapy (3rd ed.). New York: Guilford. Santiago-Rivera, A., Arrendondo, P., & Gallardo-Cooper, M. (2002). Counseling Latinos and la familia: A practical guide. Thousand Oaks, CA: Sage. Selvini-Palazzoli, A. (1974). From the intrapsychic to the transpersonal approach: to anorexia nervosa. (A. Pomranz, trans.) London: Human Context Books. Shaw, M. (1964). Communication networks. In L. Berkowitz (Ed.), Advances in experimental social psychology (Vol. 1), (pp. 111–147). New York: Academic Press. Sherif, M. (1936). The psychology of group norms. New York: Harper. Spierings, J. (2004). Multicultural EMDR. Handen, CT: EMDR Humanitarian Assistance Programs.

66 Group Leader Facilitation Attributes and Skills Stolorow, R. (1986). Toward a functional definition of narcissism. In A. Morrison (Ed.), Essential papers on narcissism (pp. 197–210). New York: University Press. Sue, D. & Sue, D. (2003). Counseling the culturally different: Theory and practice (4th ed.). New York: Wiley. Thibaut, J., & Kelley, H. (1959). The social psychology of groups. New York: Wiley. Torres-Rivera, E., Wilbur, M., Roberts-Wilbur, J., & Phan L. (1999). Group work with Latino clients: A psychoeducational model. Journal for Specialists in Group Work, 24, 383–404. Trotzer, J. (2011). Personhood of the leader. In Robert K. Conyne (Ed.) The Oxford Handbook of Group Counseling (pp. 287–306). New York: Oxford University Press. Tschusckke, V. & Dies, R. (1994). Intensive analysis of therapeutic factors and outcome in long-term inpatient groups. International Journal of Group Psychotherapy, 44, 185–208. Tuckman, B. (1965). Developmental sequence in small groups. Psychological Bulletin, 63, 384–399. Weakland, J. H., Fisch, R., Watzlawick, P., & Bodin, A. M. (1974). Brief therapy: Focused problem resolution. Family process, 13(2), 141–168. Weber, R. (2006). Principles of group psychotherapy. New York: American Group Psychotherapy Association. Yalom, I. (1995). The theory and practice of group psychotherapy. (4th ed.). New York: Basic Books. Yalom, I., & Leszcz. M. (2021). The theory and practice of group psychotherapy (5th ed.). New York: Basic Books. Zander, A. (1996). Motives and goals in groups. New Brunswick, NJ: Transaction. (Original work published 1971).

Chapter 4

Art Activities Drawing and Collage

Introduction: Drawing Activities There are few studies on art activities in groups especially for drawing and collage. Most studies are about the uses of art activities with individuals, or with large numbers of subjects that are not in a group therapy setting, such as the 133 subjects in a study on drawing and pain by Ohnmeiss, Vanharanta, and Elkholm, 1999, where the subjects were not in therapy groups. Only one study was found where group members participated in a drawing activity. Nowicka-Sauer (2007) reported on the results for three of 38 women with lupus (SLE) who participated in a group session. The analyses concluded that the drawings were a rich source for understanding patients’ perceptions of their condition, and the psychological dimensions for living with it. Numerous studies point to the efficacy of drawing with individuals as a means for expressing thoughts, feelings, and ideas about their issues, conditions, or concerns (Gonzalez-Rivera & Bauermeister, 2007; Ohnmeiss et al., 2000; Hopperstad, 2008; Lev-Wiesel & Liraz, 2007; Guillemin, 2004). These studies were conducted in many countries – Puerto Rico, Sweden and Finland, Norway, Israel, England, and the United States – and with all ages, and variety of conditions, all of which emphasizes the multicultural applications for drawing. What is missing and very much needed are studies on drawing as an activity in group therapy where the focus is not on interpreting the drawing product, but is used as a means to facilitate members’ expressions, present them with new personal awareness and understanding, demonstrate and highlight similarities among group members, and overcome resistance in a non-threatening and supportive manner. The use of drawing described here does not require specialized training, such as with art therapists, nor are the products interpreted by the group leader. Drawing is used as a means for individual expression for current experiencing by group members, and if any deeper or past concerns or issues are tapped, the individual themself identifies these. The group leader is the facilitator only for this exploration and does not act as an interpreter for the drawings. DOI: 10.4324/9781003251989-4

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Benefits and Advantages for Drawing Activities What are some benefits and advantages for drawing in the group setting? Discussed are uncontaminated expressions, focusing awareness, bypassing defenses, identifying important components, relieving tension, and helping to organize chaotic thoughts and feelings. Each benefit and advantage also has a sample activity to illustrate the focus:






Focuses awareness on important aspects of self that were nonconscious or unconscious Bypasses some defenses, such as intellectualizing Assists members in identifying important components or aspects of self, problems, situations, and so on Can relieve tension, and give an opportunity for play and creativity Helps to organize chaotic thoughts and feelings

Uncontaminated Expressions Drawing can allow each member to express personal thoughts, feelings, ideas, and awareness at the same time, and these will not be contaminated by hearing what others have to say. Group members will have numerous and dynamic unspoken and unexamined thoughts, feelings, and ideas during group sessions. These are unspoken for a variety of reasons, but major reasons are the need to have only one person speak at any given time, and the time available in a group session. To these are added individual members’ tendencies to minimize their experiencing, fear the potential for embarrassment for speaking about this experiencing, fear of offending, suppression to avoid conflict or other disagreements, a need to appear in control and competent, and many other such states. All expressive processes could facilitate expression, and drawing is one activity that group leaders will find useful. In addition, some members may have limited vocabularies and do not have sufficient words to verbally express their thoughts, feelings, and ideas. They may try to express these, but can become frustrated and/or be shamed when their words are inadequate expressions for what they are thinking and feeling. Drawing can provide another means for expressing these; allow complex and complicated thoughts, feelings, and ideas to be simplified and expressed; and can be reassuring and encouraging for the person that they can be understood in spite of the limited vocabulary.

Guidelines for Drawing Activities The basic guidelines for activities are presented in Chapter 2. Presented here are the preparation steps for drawing activities; gather materials and prepare expansion and enhancement topics.

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Gather Materials Drawing materials for these activities are very simple and modest. It is recommended that the following materials be gathered in advance of group sessions so as to have them readily available:







Several sizes of drawing paper, 8½”  11” and larger. Look for pads of newsprint. Sets of crayons, felt markers, or colored pencils sufficient so that each member can have a set, or so that no more than two members have to share these. Pencils and/or pens for drawing. Unlined index cards, 3”  5” and 5”  8”. Masking tape for mounting products on the wall or board. Other kinds of drawing paper if you desire.

Prepare Expansion and Enhancement Topics When you have a lot of experience under your belt, you’ll already have your topics ready to use in the group. But, until you do gain this experience, it will be very helpful to develop your exploration and enhancement topics in advance, and to write them on an index card. The topics should relate to the purpose for the drawing activity, members’ triggered feelings, other associations and awareness that may emerge, and similarities among group members. These topics are usually presented in the form of open-ended questions for members to respond to, such as the following:





What feelings did you experience as you completed your drawing? As you reported to the group? What are you aware of as you look at your drawing? Are there any associations with past events, people, or unfinished business that emerged for you? What was easy or hard about the task?

Each of these can serve as a stimulus or guide without overly structuring the responses, and can permit members to have their own unique personal experiences. Following is a sample drawing activity that may help some members with expressing their feelings. Activity 4.1 Express Feelings Materials 5”  8” unlined index cards, a set of crayons, colored pencils, or felt markers for each group member.

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Procedure 1 2 3

4 5

Distribute materials. Ask group members to draw symbols for three to five feelings they think would be easy to express in the group. Give time for members to share their symbols and feelings, but don’t explore these unless the group member does so on their own. Give only empathic responses. Turn the cards over and have members draw symbols for three to five feelings they think would be difficult to express in the group. Repeat step three, only this time try to get members to assess if the difficulty is of long-standing such as wanting to be liked, or if there is something about the group, or if they are unaccustomed to expressing these feelings.

Focusing Awareness Each expressive process has the potential for focusing members’ awareness, and a carefully selected drawing activity can increase their awareness for important aspects of their selves. The act of drawing can reveal current experiencing which, in turn, provides associations in the present to past events, issues and concerns that were not immediately apparent on the conscious level. For example, completing the life satisfaction activity described later in this chapter could enable members to identify current areas of concern that had not yet risen to the level of awareness, to become more aware of positive lifestyle behaviors and relationships, and to increase awareness of how their past continues to influence them in unanticipated and unexpected ways. The following drawing activity demonstrates how an activity can be used to help group members to become more aware of their immediate reactions. Activity 4.2 Immediate Awareness Materials Paper and crayons, colored pencils, or felt markers, and a suitable surface for drawing. Procedure 1 2

3

Distribute materials. Ask group members to draw symbols or representations for all the awareness they have at this moment for themselves, other group members, and for the leader. The symbols are for their thoughts, feelings, sensations, and so on, at this moment. Allow five to ten minutes for the drawings.

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Reporting phase – ask members to first share their symbols. When time permits, the expansion phase can give members an opportunity to explain their meanings for their symbols, to note similarities and differences among the members, and to express the feelings that emerged as they drew and talked about their symbols.

Bypass Defenses Drawing tends to bypass defenses that prevent material from emerging into awareness. The act of concentration on what is needed to produce a product puts the energy that was used to suppress or deny into creating. Some people may be able to consciously lower their defenses, while most everyone can be unaware when they are mounting their defenses, and neither can be aware of what they are defending against. Becoming aware of how and when personal defenses are used can lead to an understanding of the material being defended, and these are major assets for constructive and productive therapy. Following is an activity that can assist members in understanding their usual defenses. Activity 4.3 My Defenses Materials Paper, at least two to three sheets per group member, and a set of crayons, colored pencils, or felt markers. Procedure 1 2

Find a suitable place for group members to draw and distribute the materials. Introduce the activity by telling group members the following: Everyone uses defenses at times, and the defense is to prevent the person from becoming hurt, either by others seeing something that they wish to keep hidden, or to keep yourself from knowing something about you that you fear may be hurtful or dangerous. Defenses are usually unconscious, that is the person is unaware that they are using a defense. The activity is intended to increase your awareness of when a defense is being used by you or by others. There will be two components: a drawing of what a defense looks like when used by another person, and what a defense you use looks like. The drawing can be representational, such as drawing a scene where you observed or used the defense, abstract, or symbolic. Following are some common defenses, and you can select a defense for your drawings, or two separate defenses one for each drawing. Here are some examples of commonly used defenses, and there are others. (Note: the leader can either give each member a list like the following or write them on a chalkboard or a piece of large paper for posting. The leader can also add to this list.)

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3

4

5 6

7

Intellectualization – analyzing or interpreting something to make it a content or factual discussion Deflection – such as changing the topic or focus Denial – refusal or inability to admit the existence of something that is painful or anxiety provoking, either internal or external Displacement – feelings toward one person that are transferred or placed onto another person Projection – putting onto another person something you don’t want to accept about yourself, and then acting toward the person as if they had what was projected

Members are to prepare two drawings, one of an observed defense that someone else used, and one for their own defense. Ask members to title both drawings. Give a time frame to complete the drawings and remind members when close to the ending time so that they know that production time will be expiring in five or so minutes. Reconvene the group in a circle and have members describe their drawings for the reporting phase. The expansion phase is used for members to describe the experiences, such as asking about their feelings that emerged while drawing, and when they saw other members’ drawings, and when displaying their personal drawings. Summarize what emerged during the reporting and expansion, and if time permits ask members to discuss what awareness emerged for them.

Identify Important Components It seems to be usual and common for people to try and get away from discomfort, especially mental discomfort that produces feelings of shame, guilt, inadequacy, incompetence, and/or impotence. We worry and fret because solutions are not apparent; we fear the possible or real negative consequences for action or inaction, there can be confusion about personal needs and wishes, and a whole host of other reasons that the important components and aspects of self, situations, problems, and the like are not fully examined. A drawing activity can help to focus on these important components. Associations the member may produce can possibly help clarify the following:






Central figures for the concern or problem Personal feelings about others that are involved Barriers and constraints that may interfere or prevent solution or resolution Presence or absence of hope for the situation or relationship Possible decisions, alternatives, and/or solutions

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An example of an activity that could help clarify the most important components follows. Activity 4.4 My Concern(s) Materials Sheets of paper and a set of crayons, colored pencils, or felt markers, and a suitable surface for drawing. Procedure 1 2 3

4

Distribute materials and explain the objective of the activity which is to clarify personal concerns. Ask group members to draw a picture that captures the essence of their most important problem, issue, or concern at this moment. Drawings are shared and during this reporting phase the leader listens to determine if the concern is clear, can be addressed in the group, or if further clarification is needed. The expansion phase could ask members to describe what would be a satisfactory outcome for their concern, and if it can be accomplished in the group.

Relieve Tension Do not underestimate the positive aspects for relieving tension for individual members and for the group as a whole. Some measure of tension and discomfort can provide fertile ground for exploration of meaningful material. However, when there is too much tension, and too much is ambiguous, then members’ energies are used to defend and protect the self. They sense danger all around and can shut down. No productive therapeutic work can be accomplished under these conditions. A drawing activity can be used just for play, or to focus on what in the group seems dangerous and causing the tension, or to increase members’ awareness of the presence and effect on them for being tense. For example, they could do an activity that asks them to draw what their thoughts, feelings, and bodies experience when they are tense. Another example follows. Activity 4.5 Tension Materials Sheets of paper and a set of crayons, colored pencils, or felt markers, and a suitable surface for drawing.

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Procedure 1

2

Introduce the activity by noting that body tension is often overlooked or minimized, and that the activity is designed to bring awareness of tension in the body. Ask group members to draw a symbol, figure, shape, or the like for what tension feels like in their bodies, noting where it is located by putting the symbol on the following parts of the page. a b c d

3 4

Tension in the head, face, neck at the top quarter of the page. Tension in the shoulders, chest, arms, or stomach (above the waist) on the second quarter of the page. Tension in the abdomen, pelvis, lower back, etc., on the third quarter of the page. Tension in the legs and feet on the bottom quarter of the page.

Ask members to share their drawings. The group leader can ask them to rate (1–10) the extent or intensity of the felt tension. The expansion phase could ask if the tension was more or less while they were drawing, after drawing, and/or did it increase or decrease when reporting.

Organize Chaotic Thoughts and Feelings Organizing chaotic thoughts and feelings can be of immense help to group members. Instead of staying mired in the chaos, shutting down, or avoiding the chaos, members could learn to deal with this for now and for the future. There is something important that can be learned about oneself through working with the chaos rather than ignoring it, or denying that it exists. For example, it is expected that members will experience some chaotic thoughts and feelings at the beginning of the group. They are concerned about their safety, inclusion, and other such matters as well as the problem or concern that brings them to therapy. A simple drawing activity that focuses on the major feelings, or concerns about the group can reduce the chaos and focus members on the more important aspects of what they are thinking and feeling at the time. Further, commonalities can be revealed fostering the emergence of universality in the group. An example of an activity follows. Activity 4.6 Organizing Internal Chaos Materials A list of possible feelings such as the one that follows or create a list that seems to fit the group, sheets of paper, crayons, felt markers or colored pencils, and a suitable surface for drawing.

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Procedure 1

Prepare a list of possible feelings members may be experiencing in advance and make enough copies for each member.

Feelings Dread Anger Anticipation Despair Hopeful

Hopeless Embarrassment Excitement Lost Contentment

Fear Guilt Relief Happy Restless

Irritation Shame Numb Sad Inadequate

2 3

Distribute the lists and drawing materials. Introduce the activity by telling members that they may be experiencing multiple feelings, with some more important than others. Ask them to read the list of feelings, add any that they are experiencing but are not on the list, and then to select a different color for each important feeling and draw a symbol for each of the feelings on the sheet of paper with the most intense feeling symbols at the top, and the least intense at the bottom. 4 After the drawings are complete, members are asked to share their drawings where they will describe the symbol, and the intensity. 5 Summarize the feelings drawn, and ask them to rate the intensity of those feelings now as the activity is ending. Many other expressive processes, such as fairy tales, can use drawing as a means for personal expression. The drawing then becomes a focus on the essence of the experience that can help identify the most important components and associations, and will capture the essence of the personal experience for the individual group member. Members can then report these experiences, associations, ideas, and so on, without unconscious contamination from that of other group members, which can happen when listening to them. This can be especially true for children. Further, members who may think or fear that something they experience is trivial or unimportant, especially when compared to what other members may report, can concentrate on their personal experience without evaluating it as being of lesser or no importance. It is important for that particular person where, what appears on the surface to be minor conceals a deeper and more significant concern or issue. Guidelines for Group as a Whole Drawing Activities The primary guides for using a group-focused drawing activity are barriers and constraints and selecting an activity. Although there are many good and valid reasons to use a drawing activity, there may also be some barriers and

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constraints. Do not fail to anticipate or recognize these as they can negatively affect members’ feelings about the group, the amount and kind of learning and insight that can occur, and may even be harmful in some instances. The group leader is in the best position to identify these possible barriers and constraints. Examples include the following:








Physical conditions that would prevent one or more members from drawing, such as a broken arm on the dominant side, or severe visual problems. Cognitive deficits that would interfere with following directions and/or gaining self-understanding. Insufficient time in the session to complete all portions of the activity. Inappropriate or insufficient working space. While some accommodation can be made to provide a flat hard surface for drawing, having to make do could be frustrating and thereby negatively affect outcomes. Using a drawing activity that is too complex and/or complicated for group members. Emotional vulnerability of one or more members to the material so that overly intense emotions will be generated by the activity. Group members fearing shame and embarrassment about their drawing ability.

Some barriers and/or constraints can be worked around, but some signal that a drawing activity is contraindicated, such as when one or more members cannot physically draw, or follow directions, or there is insufficient time to complete the activity. On the other hand, if all members can participate, an activity to relieve tension doesn’t usually present barriers and constraints. The guiding principle is that the group leader gives some attention to consideration of potential barriers and constraints. Selecting a drawing activity can be fairly easy as many are presented in this book and are readily available from other sources. Almost all presented here can be adapted or modified for the specific group’s purpose, and to meet the abilities of group members. Other considerations for selection include the following:







The focus should be narrow and specific. Too much complexity can be confusing and use the time and energy that should be on the purpose. The concepts illustrated should be easily understood by group members. Drawings need not be representative. Symbols, splashes of color, and other abstract expressions can be helpful for some clients. Group members’ abilities should fit the drawing requirements. All materials should be readily available for every session. The drawing action should be relatively short as the most important tasks are reporting, and the exploration and enhancement phases.

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Group leaders may want to collect some activities that they’ve experienced and found useful. These then become activities that can be adapted for various purposes and audiences. It is helpful to remember that the drawing itself is the stimulus for members’ personal material and associations, and that is its main purpose and value. Almost any drawing can be the stimulus so you don’t have to spend an inordinate amount of time searching for the activity that will be perfect. Examples for Group-Focused Activities Presented are some examples for activities with a group focus. Other activities may be found in the chapter on Applications.









Assisting introductions in the first session Relieve tension Clarify members’ wants, needs, desires, and wishes Identify barriers and constraints for the group, such as resistance Teaching members how to give and receive constructive feedback Practice problem-solving and decision-making Provide a means for expressing difficult, unpleasant, and/or unacceptable feelings Foster the emergence of therapeutic factors such as universality, encouraging hope, catharsis, and identifying unresolved family of origin issues and other unfinished business

Introductions can be facilitated with a short drawing activity where group members are asked to present something non-threatening about themselves. The anxiety and uncertainty that members can experience can make them resistant to revealing anything they consider to be potentially embarrassing, or that will lead to rejection and exclusion. There can be apprehension about letting oneself be seen by others as these are strangers, or even when the other group members are known to each other. Some group members will be unsure about what personal information to disclose, some members may not be articulate, some can be wary and cautious, and other such states where an activity could be facilitative. Two examples for introductory drawing activities are as follows. Activity 4.7 Saying Hello Materials 5”  8” index cards, and a set of crayons, or colored pencils, or felt markers for each person.

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Procedure Ask members to use the crayons and draw a symbol for each of the following:





Favorite pastime Valued possession Favorite color Favorite season of the year

Activity 4.8 My Accomplishments Materials 5”  8” index cards, and a set of crayons, or colored pencils, or felt markers for each person. Procedure 1

Ask members to introduce themselves by drawing a symbol for each of the following:




Greatest achievement A talent and how it is used An aspiration, and how they are working on this

Relieving tension could be of value to the group, especially when that tension is retarding group progress. Tension is a result of fear, and each member can fear something different, but the outcomes are the same. For example, it doesn’t matter if one member fears being shamed, another fears offending, another fears being attacked, someone else fears being rejected, and another person fears appearing stupid. They are all tense, fearing the worst. The group leader may not know the individual fears, but is very aware of the tension. A short drawing activity could help relieve some of the tension so that the group could move forward. If the tension occurs during the beginning stage of group development, the drawing activity should be something light and non-threatening, such as the introductory activities presented previously. Examples of activities for the second stage (conflict) are presented in Chapter 11. Other tension-relieving activities are presented in the section on mindfulness in Chapter 7. Clarifying wants, needs, desires, and wishes can assist members in making realistic choices and decisions, becoming aware of illogical and unrealistic thoughts and expectations, obtaining a clearer focus and/or achievable goal, and in identifying self-imposed and externally imposed barriers and constraints. Lack of knowledge, chaotic circumstances, insufficient self-understanding, and other such states can make it difficult for group members to have a clear sense of

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what they want, need, desire, and wish for, and the extent to which these are reasonable, achievable, and will lead to the desired outcome(s). When members have a clearer understanding of needs, wishes, desires, and wants they can be more motivated to have a realistic action plan, to relinquish unrealistic fantasies and expectations, to make needed changes, and to gain self-confidence. They begin to explore avenues that serve as alternatives to achieve the goals, to learn strategies to work around or overcome barriers and constraints, and to understand how they are contributing to not getting what they want, need, wish for, or desire, that is both realistic and achievable. Giving up the fantasies will be the most difficult task, and this can take considerable effort. Common fantasies include the following examples:










The other person must or will change. Unlimited wealth, success, and the like. Attention and/or admiration will be theirs without effort. All others will perceive them as unique and special. Effortless winning of others’ approval and acceptance. Others will read their minds and give them what they want or need at all times. They will be powerful enough to make others bow to their will, to change others, to tell others what they need to do or be, and this will be carried out without dissent. They will never have to suffer or worry, and will be happy all of the time. They can do what they want to without negative consequences.

Drawing activities can be a non-threatening way to make resistance visible, to heighten awareness of its existence and possible reasons for this, and to suggest ways to moderate or eliminate it. A further positive outcome could be an understanding of personal resistance and its role and contributions to forming and maintaining meaningful relationships. It is generally not helpful to directly attack resistance as this can solidify defenses, or leave the person unnecessarily vulnerable to overwhelming emotions and/or memories. It is much more helpful when the person themself chooses to explore the resistance and make a decision to let go of it. These are some of the reasons why it is best to let resistance alone, and to use some nonthreatening means to highlight it. Word choice can make a difference also as some members can perceive resistance as wrong, feel guilty or shamed, instead of being open to exploring the personal function the resistance is serving. When introducing an activity to highlight resistance, use phrases such as the following (Activity 4.9 illustrates how an activity could be used to get around barriers and constraints such as resistance):


What in the group, or in yourself, feels like it’s getting in the way of your participation, or disclosure, or feeling safe, or the like?

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What feedback do you want to give or receive that is absent? What does this group feel like to you? Describe, or use a symbol to depict the space between you and other group members.

Activity 4.9 Wishes for the Group Materials Crayons or a set of colored pencils or felt markers, paper. Procedure 1 2

Introduce the activity by telling group members that it could be helpful to get each member’s perception of the group. Ask members to select a different color for each and to draw symbols for each of the following:





3 4 5

The most important wish they have for the group What seems to be a constraint or barrier in the group What they want or need from other group members An overall feeling about the group

When members have finished their drawings ask them to present them to the group. After all sharing and responding is complete, ask members to title their drawings and report these to the group. Summarize the essence of the drawings for how members are feeling about the group.

Constructive feedback is very helpful to group members and the group’s progress, and members’ growth and development are facilitated by such feedback. It is most likely that group members will have to overcome fears for both receiving and giving feedback, and will need to be taught how to make their feedback constructive. Drawing activities could be facilitative for focusing feedback, verbalizing fears about offending and rejection, show commonalities among members, and as a means for giving constructive feedback that can be accepted and used. Drawing activities can facilitate the focus for feedback and, at the same time, reduce the potentially threatening nature of the feedback since all group members will be participating, no one member is singled out to receive feedback or is put on the hot seat, and the group leader structures and direct the activity to focus on important aspects of the self. For example, group members could be asked to draw a symbol for a characteristic they have observed about every member. Another facilitative activity could be to have group members

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draw symbols, or select a color for the apprehensions and/or fears they have about giving or receiving feedback. Problem solving and decision-making can usually be accomplished by having members set goals, determine steps to reach the goal, identify constraints, and develop an action plan. However, there are times when members are so confused and frustrated that they cannot see their way clearly to work through these procedures. This is where drawing activities could be of assistance. For example, a drawing activity could help members realize that their wishes and fantasies are getting in the way of their problem-solving or interfering with making decisions. They are not using their resources or competencies, they are insisting that others change to suit them, or that magic will change circumstances so that they can prevail. The activity could clarify their unrealistic expectations, thus clearing the way for them to work through a constructive and productive procedure. Drawing activities can also suggest alternatives to address problems or other options for decisions. The resources of the group can be used in this way for each group member to address their problem, or could be used for each group member to propose alternatives for one member’s problem or decision. Projecting outcomes and consequences can suggest new strategies, or even use a combination of the proposed alternatives and options. This use of drawing is another way of collaborative brainstorming that permits each member to create ideas and to share them. Activity 4.10 Desired Outcomes Materials Crayons, or colored pencils, or felt markers, paper for drawing. Procedure 1

2 3

4 5

Ask members to close their eyes and go into the future and see the desired outcome they want. Stay with the picture for a while, noticing as many details as possible, and their feelings. Give a few minutes for the pictures to emerge, and then tell members to open their eyes and draw what they saw. The group leader should respond empathically during the sharing period, but don’t explore or point out the illogic or unreasonableness of the desired outcome. After sharing is completed, ask members to rate the possibility of the desired outcome, and its reasonableness. This is shared among members. The final step is to have members describe what steps they could take to get the desired outcome, or to change their longing to a realistic outcome.

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Expression of feelings can be expedited with drawing activities as these don’t require words that members don’t have, or are unable to verbalize, seem threatening or dangerous for various reasons, are unacceptable, appear to be potentially shaming, and/or are abstract, complex, and difficult to describe with words. There are numerous reasons why group members could be assisted in expressing their feelings, and drawing could be one way to facilitate this. There are also some group situations where drawing could aid emotional expression.



Members who tend to intellectualize, story-tell, or monopolize would not be able to hide behind words. Members who are avoiding expressing their feelings because these are troubling or intense would have an opportunity to express these.

If there is conflict, or denial of conflict, a drawing activity could aid expressing emotions that accompany the conflict without having to directly address the threatening conflict. Examples of other creative activities for group focused concerns are presented in other chapters and are a focus for Chapter 11. Collage This section describes how collage can be used in and with group therapy, possible uses for flats (paper-doll representations of self or pets), and other expressive activities that are difficult to categorize. Collage is just another creative format for expression that can be more appealing for people who are apprehensive about drawing. Being asked or expected to draw can raise many fears about personal adequacy and rejection by others. Collage is much less threatening and group leaders will face much less resistance. Aimone (2000) defines collage as being any material that is attached to a surface, simple or complex, and constructed without boundaries or rules. Because collage is truly a combination of art and crafts, it is well suited for use in therapy groups where expression is more important than artistic talent, and where literally anything goes. Effective use of collage begins with the group leader’s understanding and practice in construction, especially if this is not something that is in the leader’s repertoire. Although a workshop or class can facilitate the learning, these are necessary as there are many books and internet-accessible resources to use as guides. This chapter will describe collage constructions and uses for groups. The first part of the discussion focuses on the leader’s development, and then presents possible uses. The Group Leader’s Development for Using Collage – This will be described in phases assuming that the leader has little or no experience with using collage.

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The first phase is an introduction, the second is practice, and the third is forming activities for the group. During the introductory phase, go to exhibitions or galleries and look at artistic collage works to get some notions about how these are constructed, materials used, and what is being depicted or expressed. You are most likely to find that anything and everything can be used in construction, and that there are many forms of expression. It can also be helpful to read some magazines as there are numerous ones on the market that are intended for non-artists, particularly in the craft and scrapbook sections. These usually have numerous examples illustrated, and descriptions provided for many of the techniques used. In some ways you don’t have to leave the introductory phase as you can continue to gather new ideas and techniques for a very long time. The next phase is the practicing phase, and this can be fun and enlightening. It is essential for the group leader to become familiar with some of the techniques used for constructing collages, as these will be needed for phase three, and may be needed as illustrations for group members. All suggested procedures and techniques are brief so as not to lose the focus and purpose for the group. Following are three practice collage activities that can also be used later in the group. Activity 4.11 My Fave Five Materials A 5”  8” index card, glue stick, scissors, and a favorite magazine or sales catalogue. Procedure 1

2 3 4

Search the magazine for pictures that represent some of your favorite things, such as something you like to do, something that gives you pleasure, symbols for anything in your life that you favor. Cut out the pictures and symbols. Arrange these on the index card, trying different arrangements. These don’t have to be symmetrical or straight. After the arrangement suits you, carefully remove the elements, and use the glue stick to replace them on the card. Title your collage.

Variations Use sheets of paper, or smaller index cards; have pre-cut images that group members can select from; use torn paper to back the images and provide a frame.

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Activity 4.12 Just Play Materials A sheet of heavy, smooth, unlined paper; white glue or a glue stick; a collection of paper and/or paint chips in one family of color, e.g. all purples; and scissors. (Note: you need a variety of colors, but not much paper.) Procedure 1 2 3

4

Cut or tear the paper and/or paint chips into various sized triangles and mix them in a pile. Select a handful of triangles and let them fall on the paper. Do this several times. Note the arrangements as they fall, and when you find one that is appealing to you, note the placement of the triangles, and carefully remove them. Replace them in the arrangement after putting glue on the back of the triangles. Title your collage.

Variation Include triangles with words or images. Activity 4.13 Collage with Shapes Materials Newspapers, magazines, and/or other print publications in black and white, e.g. brochures and catalogues; a sheet of paper 8½”  11” or larger; scissors; a glue stick; a black sheet of paper and a white sheet of paper; and a variety of small objects such as buttons, bottle caps, string, and the like. Procedure 1

2

3

Decide first on what shapes you want to use, for example: hearts, flowers, stars, or some other simple image. If you have something like a cookie cutter that you can trace around, this could be your shape. Trace the shape on the newspaper or print publication that you decide to use, and either tear or cut out the shape. You will need three to four large shapes, or six to eight smaller ones. If you need more shapes after you start creating your collage, you can cut or tear more. Carefully tear two 1½”  11” strips each of the black and the white paper.

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Glue the long strips to your paper, overlapping them slightly. Arrange your shapes on the glued strips. Distribute your objects on the shapes and/or strips, and glue down. If the object is large or bulky, you may need to use a glue spot to attach them. Title your collage.

Preparation For Use in Group The first step when using collages in a group is to gather and prepare materials in advance. Cut out images and shapes so that members then only have to choose what they want to use. Having images cut out in advance can facilitate the production, especially in those environments where scissors or other cutting implements may not be feasible or allowed. Try to have a variety of these in case more than one member wants the same shape or image. The value of using images is that these can serve as symbols, and many different images can symbolize the same thing. Following are some topics that could be the basis for collages:








Dreams and wishes for the future Greatest accomplishments Biggest disappointment Values and beliefs about oneself Positive personal attributes Any feeling word; happy, excitement, sadness Concepts such as conflict, intimacy, inadequacy

Depending on the complexity of the collages and the time available in group sessions, some could be given as homework. Another alternative, if there is space and it is appropriate for the group, is to let members come to a session early to make their collages. Basic materials include the following:












A variety of paper in different sizes and colors Several pairs of scissors Sets of colored pencils, crayons, and felt markers Old magazines and catalogues Pens, pencils. and permanent marker pens Twigs Paper clips in a variety of styles and colors Glue sticks, white glue, transparent tape, and double stick tape Cardstock or other heavy paper in a variety of colors, cardboard, canvas, or other suitable backgrounds for collage A variety of objects such as string, yarn, button, safety pins, fabric scraps, embroidery thread, sequins, and so on Index cards: 3”  5” and 5”  8”, unlined are best but not critical

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It is also helpful to have printed sets of directions available, especially if the collage is for a special project. Otherwise, just let members create on their own. Focusing the Activity As with all creative activities, collages should have a purpose and goals that relates to the group and to members’ needs. While these can be created just to relax and have fun, that too is a goal and purpose, to reduce stress and tension. Possible goals and purposes include the following:












Reveal an unidentified strength Increase awareness of accomplishments Assist in expressions for thoughts, feelings, and ideas Clarify goals, wishes, and fantasies Develop a creative part of self Give expression to abstract concepts, such as hope Make sense of chaos, overwhelming stimuli, and complexity Reduce intellectualizing, hiding behind words, masking feelings Highlight commonalities among members, and forge connections Increase feelings of being understood, competent, and of life’s successes Assist in making associations and linkages to important personal material

After determining the goal and purpose, it becomes easier to select the topic for the collage activity. This, along with an introductory rationale, should be written and read to the group when the activity is presented. It is easier to write this in advance rather than trying to remember the important points, or to create it as you stand or sit before the group. The introductory rationale should include behavioral manifestations of a need, such as noticing that members tend to minimize their strengths. Or, that members are avoiding conflict, and that making a collage will enable each member to express their fears or other feelings about conflict. The group leader needs to plan and select the activity so that there is sufficient time for construction and sharing. Exploration and expansion may be possible, but just creating and sharing can be sufficient at times. This is why it is important to select an activity that doesn’t take the majority of session time to construct. If it becomes important and/or meaningful to have group members explore more complex issues through collage, this can be given as homework, or to be completed in space outside the group. A guide for construction time is that it consumes about 25% of session time at the most. For example, if the session is 60 minutes, construction time would be no more than 15 minutes. Using already cut out images, and the like can expedite construction. Practice by constructing a collage on a 3”  5” index card this way, and you’ll see that you can do a lot in 15 minutes. Some members may feel rushed, but restricting the amount of time can sometimes reveal more meaningful material as

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restriction forces the use of free association and reduced defensiveness. Their focus is more on production and less on resistance. Some relatively quick-to-construct collage topics are the following, especially when materials are prepared in advance of the session:








Two to three closely held values A dream for the future My talents Enjoyment Hurt, sadness, grief Acceptance and positive regard Anger, conflict, disagreements

Activity 4.14 Who Am I – My Physical Self? Materials 3”  5” unlined index cards; cut out pictures of food, medicines, recreational and exercise activities, sports, relaxation, pillows, mattresses, sleeping aides, images reflecting doctor visits, toothbrushes, toothpaste, dental images, and other physically relative images including some that are not ideal or healthy; blank sheets of paper; glue sticks; scissors; and pens or pencils. Construct samples of 3”  5” collages to use as illustrations. Procedure 1 2

3 4 5

6

Distribute index cards and arrange images on a table where members can sort through them, and can construct their collages. Introduce the activity by telling members to select images that depict their physical selves at this time, and glue them on the card to construct a collage. Images can be arranged in any formation on the card. Give a time limit, such as 15 minutes. Reform the group circle and have members display and explain their cards. Distribute the pens or pencils and sheets of paper and ask members to write a brief paragraph about their “physical self at this time”; feelings aroused as they constructed their collages, and areas of satisfaction and dissatisfaction. Reform the group and have members report any awareness that emerged from either or both parts of the activity, and/or other thoughts or feelings.

Following are the variations that can be used to depict other parts of members’ selves. Use the same procedures as described for physical self.

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Activity 4.15 My Emotional Self Materials 3”  5” or 5”  8” index cards, paint chips samples in a variety of colors; images that could be symbols for feelings, such as tears or tombstones for sadness and grief; glue sticks; scissors; crayons or colored pencils or felt markers. Instructions to Group Members Construct a collage that depicts your most easily expressed feelings, or those that are most difficult for you to express openly and directly. Activity 4.16 My Inspirational Self Materials 3”  5” or 5”  8” index cards, crayons, or colored pencils, or felt markers; images of beaches, mountains, and other scenic wonders; images that appeal to you as inspirational and those that you think would appeal to others or get them thinking about their inspirational self. (If a member or member wants to equate inspirational with religion ask them to find or draw their own religious symbols as these can be very personal and unique for them.) Plain sheets of paper for drawing, scissors, and glue sticks. Instructions Reflect on your inspirational self and construct a collage that conveys your sense of your inspirational self. Activity 4.17 My Creative Self Materials 8½”  11” cardstock in white or a neutral color; newspapers, magazines, and other print publications; scissors; glue sticks, white glue; crayons, watercolors, and/or poster paints; two or more example collages prepared in advance. Instructions Construct a collage that reflects your creative imaginative self. You may be creative in ways other than art, and your collage can reflect this. Other avenues for creativity include writing, cooking, gardening, sewing and other needlecrafts,

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dance, music, acting, fixing broken objects, and so on. Think of your creativity as the part of you that produces new and novel products and/or processes. It can be helpful for the group leader to provide samples for collage activities. Two suggestions for example collages prepared in advance follow. EXAMPLE 1

Tear long strips (12”) of newspaper and glue to white cardstock leaving spaces between the strips. On another piece of newsprint, lightly draw a simple small house outline, color it with the crayons, watercolor or poster paints, and let it dry. When it is dry, cut it out leaving 1” or more all around, and glue to another piece of cardstock and let dry. Now, cut the house out around the lines, and glue to strips on the other piece of cardstock. Look in your drawers, purse or pocket, and find things to put on the hours and/or strips. These are the embellishments for your collage. Title your collage. EXAMPLE 2

Draw or trace three large simple flower shapes on newspaper or other print material, color in the flower shapes, cut out with a border, glue to cardstock and let dry. When dry, cut out the flower shapes and glue to a large piece of cardstock. Repeat the process for three medium, three small, and three very small flower shapes. Stack three piles of flower shapes so that each stack has a medium, a small, and a very small flower shape. Fold each flower shape in half, crease and put a narrow strip of glue down the backside of the crease. Glue the stacked flowers and let dry. After drying, put a narrow strip of glue down the back of each medium flower and place these between the larger flower shapes on the cardstock. Use buttons, coins, or other small round objects for the center of the flowers.

Additional Collage Activities Activity 4.18 Inside/Outside Materials Large envelopes 5”  9” or larger; images from magazines or catalogues (the leader can have a collection of these cut in advance, or provide a variety of magazines and catalogues where members can find images), glue or other adhesive, pen or pencil; and a set of crayons, or colored pencils, or felt markers. Procedure 1

Distribute the materials and ask members to construct a collage on the outside of the envelope that illustrates what they find easy to disclose to

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others, how they see themselves, and how they think others see them. They are to find images that illustrate what they find difficult to disclose, and their internal selves and put these inside the envelope. They will not have to share what they put in the envelope. Give a timeline for construction and notify members when about five minutes are left. Ask members to describe the outside of their envelopes, but do not do exploration at this time. After all members have shared, lead a discussion on what the experience was like, e.g. feelings and thoughts, was it hard or easy to find descriptive images, and what summary statement would they make about the external collage.

Activity 4.19 Home Materials Cardstock, cut out images, paper scraps, glue, scissors, and a set of crayons, colored pencils, or felt markers for each participant. Procedure 1

2 3

4

Distribute the materials and ask participants to make a collage about the place or building that gives them a feeling of home. The home can be past, present, or a wish. The home can be representational, abstract, or symbolic. It is whatever they choose to create. Announce the timeframe for constructing the collages and remind them of the remaining time available about five minutes before you call time. Return to the group circle and ask participants to describe their collages. Don’t explore at this time unless there are considerable emotions aroused in the participant. All participants must have sufficient time to report on their collages. Next, ask them to describe their feelings as they thought about “home”, as they constructed the collage, as they displayed their collage to the group, and as they listened to others talk about their “home”.

References Aimone, K. (2000). Creative collage for crafters. New York: Lark Books. Gonzalez-Rivera, M., & Bauermeister, J. (2007). Children’s attitudes toward people with AIDS in Puerto Rico: Exploring stigma through drawings and stories. Qualitative Health Research, 17(2), 250–263. Guillemin, M. (2004). Understanding illness: Using drawings as a research method. Qualitative Health Research, 14(2), 272–289.

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Hopperstad, M. (2008). How children make meaning through drawing and play. Visual Communication, 7, 77–96. Lev-Wiesel, R., & Liraz, R. (2007). Drawings vs. narratives: Drawing as a tool to encourage verbalization in children whose fathers are drug abusers. Clinical Child Psychology and Psychiatry, 12, 65–75. Nowicka-Sauer, K. (2007). Patients’ perspective: Lupus in patients’ drawings. Clinical Rheumatology, 26, 523–1525. Ohnmeiss, D., Vanharanta, H., & Elkholm, J. (1999). Relationship of pain drawings to invasive tests assessing intervertebral disc pathology. European Spine Journal, 8, 126–131. Ohnmeiss, D., Vanharanta, H., Estlander, A., & Jamsen, A. (2000). The relationship of disability (OSWESTRY) and pain drawings to functional testing. European Spine Journal, 9, 208–212.

Chapter 5

Writing Activities Essays, Lists, Journals, Poetry, and Cinquains

Introduction Writing activities are a means for expressing and exploring thoughts, ideas, and feelings to elaborate, clarify, and understand these. While generally used as communication to others, writing activities are used in therapy primarily in communication with oneself to better understand what you are thinking, feeling, imagining, and associating. These activities can provide a thread that links the present, the past, the nonconscious, and unconscious, and can provide access to previously unexplored parts of self. Writing can differ from other expressive activities in its ability to cover more material in less space and time, can be a personal and private way to engage in self-exploration but also benefits from being shared with others, and has various modes for implementation. This chapter presents a variation for Expressive Writing (Pennebaker, 1997a) which is a copyrighted writing activity, an autobiographical activity, expansion for life events, connecting the past to the future. Also presented are 14 different writing activities for general writing, poetry, writing for a single session, and journaling.

Benefits From Writing Activities Oatley and Djikic (2008) define writing as “thinking that uses paper and other media to externalize and manipulate symbolic expressions” (p. 9). Getting one’s thinking written down can accomplish several goals: 1 2 3 4 5 6 7 8

Communicate these thoughts to others Organize and order the thoughts Helps to make meaning, and to make that meaning clear Express abstract and complex inner experiencing Reveal hidden connections and associations Allow the imagination to be expressed Encourage and promote creativity Provide inspiration and hope to self and to others

DOI: 10.4324/9781003251989-5

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9 Clarify complex situations, relationships, and events 10 Provide a guide on how to do something, such as what this book does Therapeutic benefits from writing can include some of the following:





















Expressing inner experiencing that is dangerous or shameful to verbally express. Writing the words can seem less threatening. Clarifying confusing thoughts and feelings can be expedited through writing. The act of trying to express the thoughts and feelings can provide a means to help sort through them, prioritize their importance, and reveal inconsistencies and irrationality. An opportunity to explore thoughts and feelings on one’s own to see where these lead. The independence and privacy afforded by writing can provide the space and time to engage in self-exploration uncontaminated by others’ thoughts or presence. A visible realization of creative thoughts and ideas can emerge. The act of putting these on paper or on the computer screen, the opportunity to review them, and the possibility of seeing different associations and alternatives can be realized through writing. Writing allows for associations to emerge, and these can provide insight and understanding. Other associations such as precipitating situations, events, and relationships can become clearer, and can provide suggestions for alternative approaches and/or responses. Writing is a means to focus on the positives in one’s life and on personal strengths. It is much easier for many people to emphasize the negatives in their lives, and focusing the writing on the positive aspects of self, and of one’s life can be affirming, encouraging, and inspiring. Defense mechanisms that may arise from verbal interactions can be reduced or eliminated. Since writing can be much less threatening, it is less necessary for the individual to be defensive about shaming incidences, thoughts, and the like. The self can be more receptive and open to considering flaws and inadequacies, thus providing more opportunities to create better ways to behave and to relate. As a way to personalize treatment when in a group. There are times when it is difficult to personalize group material because of the complexity of the group, the dynamic movement, the confounding that can occur from others’ stories and responses, and so on. Writing about one’s personal experience is a way to sort through that person’s thoughts, feelings, ideas, reactions, associations, and the like without the confounding that can occur when interacting with other members. While that constructive responding and feedback is valuable, it is sometimes more helpful for the individual members to personalize their understanding and analyses prior to sharing these with the group.

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Center and ground oneself in the present. Writing can be a means to bring the members into the here and now, and support their emotional presence in the group. Outside concerns, past experiences, and the unconscious continue to affect present experiencing, but becoming centered and grounded in the present expedites the work of the group and for the individual members.
Assist with planning for the future, such as writing action plans and anticipating barriers to these plans. When group members write these, they increase their awareness of the possibilities, their potential, and can even create possible alternatives and solutions.
Conveying thoughts, ideas, and feelings to others. This can be especially helpful when what is being discussed carries intense emotional content that can make it difficult to select the words to adequately express what is intended. Writing these thoughts etc., provides opportunities to sort through the myriad of feelings, to select words and phrases that are accurate representatives of the feelings etc., and to lessen intensity of feelings by becoming more cognitive.

How and Why Writing Can Help Robinson (2000) proposed that “research shows that the majority of people who write regularly feel that it helps them cope with and work on traumatic experiences and is beneficial to their well-being” (p. 83). He discusses how the process of writing relates to beneficial outcomes. It would appear that both what is written, and the process of writing have benefits. Robinson uses Wilma Bucci’s model (1995) as a basis for understanding the process. This model assumes that experiences are stored in the mind in symbolic and non-symbolic forms and that only symbolic forms are available for verbal communication and thought, both written and oral. The non-symbolic forms appear in images, emotions that seem to have no label, and other internal representations of experiencing. Language is one way to try to connect to the nonsymbolic form via referential activity by naming the experience and/or feeling, and to identify this (Bucci, 1995). There are four stages for this process: Activation, Referential 1, Referential 2, and Reformulation. 1 2 3 4

Activation – Nonsymbolic images and/or feelings are activated. Referential 1 – Internal images are formed that have referential meaning. Referential 2 – These images are put into words. Reformulation – The words assist in reformulation of the non-specific images or feelings into known images or feelings.

This process illustrates the possible benefits for writing, and both the outcome and the process contribute. Insight, understanding, and assimilation of experiences can be facilitated for therapeutic benefit. Layers of ambiguity,

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unawareness, and uncertainty can be stripped away so that meaning becomes clearer, and a burden can be lifted. Writing activities can be especially helpful in a group because they allow all members to participate at the same time, and personalize the material. The group leader does not have to be as concerned about what other members are experiencing while working with one member. In addition, the use of journals and other writing as homework can enrich and deepen the group experiences for group members. The remainder of the chapter describes Pennebaker’s Expressive Writing, poetry, journals, and selected activities.

Expressive Writing Pennebaker (1997b) and Esterling et al. (1999) studied the effects of disclosure writing, termed expressive writing, effects on health, and found that there were many positive effects. The basic format for Expressive Writing asks participants to write for 15 minutes each day on a topic for three days. The topics could be the participant’s choice, or specific topics such as cherished values, life goals, or a traumatic experience. Since Pennebaker began his studies others have conducted studies, and he notes that the many studies on expressive writing show the following effects on participants:





Immediate and long-term cognitive changes Immediate and long-term emotional changes, such as reduction of negative affect about a trauma (Park & Blumberg, 2002) Positive changes in participants’ social and relational lives Gradual and cumulative biological effects, such as better physical health

Hundreds of studies have been conducted using expressive writing for a variety of conditions and subjects with mixed outcome results. The technique seems to produce positive outcomes in most cases, but also tends to show positive outcomes for narrowly focused and specific conditions. For example, in the study by Koopman et al. (2005) using expressive writing effects changes in pain, depression, and Post-Traumatic Stress Disorder (PTSD) symptoms for survivors of intimate partner violence; they found that depressed women showed a significant drop in depression, but the main effects were not significant for changes in pain or PTSD. Sloan, Marx and Epstein (2005) found that expressive writing with high-risk drug dependent patients at a primary care clinic who wrote about the same traumatic event over three session had significant reductions in physical and psychological symptoms in comparison with a control group writing about different or non-traumatic events over three sessions. Samples of other studies on conditions and subjects include the following:



Rape (Brown & Heimberg, 2001) Sexual abuse (Batten, Follette, & Palm, 2002)

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Cancer (Sloan, et al., 2005) Rumination and depressive symptoms (Gortner, Rude, & Pennebaker, 2006) Prisoners and illness (Richards, et al., 2000) Coping with job loss by engineers (Spera, et al., 1994) Young adult smokers (Ames, et al., 2008) Maternal psychological distress (Barry & Singer, 2001)

Chan and Horneffer (2006) compared an expressive writing group, a drawing group, and a control group on psychological symptoms before and after two 15-minute writing sessions. The expressive writing group had a significant decrease in their symptoms compared to members of the other two groups. The analysis did not identify specific symptoms that showed a decrease, just that there was a general overall lessening of emotional distress. Another approach to using expressive writing is described by Reisman et al. (2006) where resident physicians were introduced to Abraham Verghese’s system (2001) for writing that focuses on integrating creative writing with clinical duties. This approach uses personal journals, parallel charts, and critical incidents reports with an emphasis on describing the event and one’s personal reactions. The purposes are to encourage reflection and awareness, increase emotional engagement and empathy, and to deepen interactions with others. The process involved having participants write on a topic relative to their experiences and feelings as residents, and a sample orally presented and discussed by other residents. The discussion focuses on the extent to which the writing aroused the reader’s/listener’s imagination. The writer listens to the discussion, but can only comment at the end. Reisman et al. (2006) reported than an unanticipated outcome was the development of group cohesiveness. The other outcomes as reflected in a qualitative analysis of themes in the writings, and a post-group focus evaluation, were increased awareness of self and others, an outlet for feelings such as insecurity and impotence, and a deeper understanding of the healing power of compassion. The approach used by Reisman et al. (2006) used the group as part of the process, which seems to have enriched the experience and even to have promoted group factors, even though that was not a purpose for the group. What may have happened that could be useful for other group leaders are the following:




Unacceptable and uncomfortable feelings expressed, were accepted and not criticized by others. Commonalities for these feelings became visible, thus promoting connections and universality. Reading aloud was nonjudgmental and intended as expansion and exploration.

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Real experiences were described and possible alternatives, options, and changes explored which promoted feelings of self-efficacy. There was an increased awareness both for self and for others, especially for those who were in a dependent state, e.g. patients.

There are many different approaches to use for expressive writing, but all seem to produce positive benefits. The following set of activities uses expressive writing, but group leaders must be aware that intense and negative feelings can be aroused. Because of this, these activities must be used with caution and the group leader must be prepared to deal with what emerges, and to even be available between sessions if members are having difficulty coping with the emerging feelings. Activity 5.1 Group Expressive Writing Materials A suitable surface for writing, pen or pencil, paper, or a bound journal. Procedure Introduce the activity telling group members that the activity could help them integrate and reduce the intensity of feelings about a distressful event from their lives. Describe the activity as being three sessions of 15 minutes of writing each session. What they write will be personal and private for them, and although you will collect the essays, you will not read them and will keep them under lock and key. At the end of the three sessions, you will destroy the essays or return them to the writer, their choice. Another option is to offer to keep them until the last group session and make the decision then. Tell members that they will write whatever they choose, without paying attention to grammar or other technical writing concerns. They can write sentence fragments, or just words or phrases, they do not have to write complete sentences. SESSION 1 – DISTRESSING EVENT DESCRIPTION

1

2

3

Ask members to think of a distressing event from their past that has a distress rating of 5 or 6 on a 10-point scale, where 0 is no distress, and 10 is extreme distress. They are to then write about the event especially noting feelings about it. Allow 15 minutes for writing. Next, ask members to review what they wrote, and using another sheet of paper make a list of the feelings that emerged as they wrote and as they thought about the event. Rate each feeling on the 10-point scale described in step 1. Collect the essays and feelings, and keep these under lock and key.

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Use the same procedure as described for session 1, where they write about the same event, list the current feelings, and give these a rating. Collect the essays and feelings. SESSION 3 – DISTRESSING EVENT REVISED

Use the same procedure described for session 1 and have them write about the same event, make a list of the feelings experienced now. Collect the essays and feelings. a b

Ask members if they want to report on how or if their feelings changed after three sessions of writing. Allow any member to opt out who wants to. Ask members how they want you to handle the essays and lists you collected; keep, destroy, return.

The next activity is also presented to be completed in three sessions. Members will write for 20–30 minutes about their lives beginning with the present. Group leaders should state that members do not have to share what they wrote but can choose to do so. The group reflection/reporting phase focuses on the writing experience and the members’ feelings. Three sessions are presented here although more sessions could be used depending on group members and the purpose for the group. Activity 5.2 An Autobiographical Activity – Session 1 Materials Sheets of paper or a journal, and writing instruments. Procedure 1

2

3

Introduce the activity by telling group members that the next few sessions will focus on writing an autobiography. They have lived their lives to this point, and the purpose is to engage in self-examination by writing about their life experiences. Instruct members to take one sheet of paper and list all of the words and phrases that apply to them to finish the lead, “Currently, I am”. You can suggest that they look at their general feelings experienced, the relationships, their work or other such activities, leisure pursuits, hobbies, interests, and so on. Who are they at this moment in time? Once that list is complete, ask them to take another sheet of paper and to write an essay on their Current Self. Allow 20–30 minutes to complete

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this portion. It may be that some will need to complete their essays outside the group session, and the leader can decide if this is appropriate for this group. After the writing period is over, ask members to reconvene in the group circle and to share what the writing experience was like for them. Questions that can guide the sharing include:






What seems focal in your life today? What awareness emerged? What seems missing or incomplete? Were there any surprises? What feelings emerged as you thought and wrote about your current life?

Activity 5.3 An Autobiographical Activity – Session 2 Materials Sheets of paper or a journal, and writing instruments. Procedure 1

2

3

4

Introduce the activity by telling members that this session will focus on their past life; its significant events, important people, meaningful and important activities, and the like. Instruct them to take three sheets of paper and to make a list of events, people, activities, and so on for three life periods: one list for childhood, a list for early adolescence 12–15, and a list for late adolescence/early adult 16–21. The next step is to select one of the lists and to write an essay about that life period. When time permits, they can write three essays, but if there is not enough time for reporting, limit the writing to one list, and use the other lists for discussion or reporting at another session. Reconvene in the group and use the items in step four of the previous activity to guide the exploration of the essays.

Activity 5.4 An Autobiographical Activity – Session 3 Materials Sheets of paper or a journal, and writing instruments. Procedure 1

Introduce the activity by telling members that this will be an exploration of their desires and dreams for their future selves.

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4

Use the same categories listed in activity 5.3 and ask members to make a list of their desires and dreams for each of these. These should be separate lists. Instruct members to review these lists and select the one that seems most important to them at this point, and to write an essay about their desires and dreams in that category, for example what they envision and want their relationships to be in the future. When the essay seems finished, ask members to reflect on steps needed to realize the desire/dream, what they are doing now that will help them realize this such as attending school to get a degree in the desired profession, and how they are resisting moving in that direction. The other lists can be used for future group discussions.

This next activity can also be autobiographical but is presented here as a single session activity. Activity 5.5 Life Events Materials Sheets of paper and a pen or pencil for writing. Procedure 1

2

3

4 5

6

Ask group members to make a list of significant events in their lives that occurred during childhood, adolescence, or as adults. They should have only one list for one period in their lives. Have members review and reflect on their lists and select one event to explore. Depending on the available time, more events can be explored with the following process. Write the event at the top of a clean sheet of paper, and then list all of the people involved, the feelings experienced at that time, and the feelings that are carried forward to the current time. Next, write a paragraph, or more, that describes the event, the impact on the person, and the lingering effects of the event on them today. Ask members to share either the event, or the feelings aroused then and now. They don’t have to share all of what they wrote as some may have written a considerable amount. Ask members to report on what the writing experience was like for them, difficulties, new awareness, etc.

Single Session Writing Activities Writing activities conducted during a group session provide an opportunity for each member to work on his/her unique issue, reduce confounding or

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emotional contagion by hearing what others have to say, can assist in organizing members’ thoughts and ideas, provide an additional means for expressing feelings, and can even tap material just below conscious awareness. Considerable learning, understanding, and insight are possible in just one session. Rationale Session writing activities are conceptualized as stimuli to focus awareness on an important topic or issue for group members, provide an opportunity for individual input, and are completed within the time frame for the session. Thus, the group leader has to select writing activities or activities that do not take much time to complete, as most of the time has to be spent on members reporting on their writing, and some exploration of what emerged. The writing portion is the stimulus for accessing group members’ personal material in the form of thoughts, feelings, and ideas. Another benefit for group members is that their writing is not evaluation, maybe for the first time ever. Misspelled words, verb-subject agreement, punctuation, and other grammatical concerns are not important, and the group leader has to make it clear that expression is the important concern rather than technical writing matters. Following are some examples for activities than can be accomplished in a single session for groups that have ten or fewer members. If the group is larger than ten, the reporting phase may be facilitated by breaking the large group into smaller groups of five or less and asking them to share their products in the smaller group. In this event, the group leader will also need to reconvene the large group and have the small groups each report on what emerged for those group members. They could be asked to report on the theme, commonalities, feelings, and the like. Refer to the basic guidelines in Chapter 3 on managing a large group.

Session Writing – Past Reflections The first set of four activities could form the focus for four sessions. These are not all intended to be completed in one session, do one activity per session. Activity 5.6 Childhood Event Materials A suitable surface for writing, a pen or pencil, and paper. Procedure Introduce the activity by telling members that the group is going to explore childhood events.

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1

2 3

4

Ask them to think of a significant event or memory they have that occurred when they were 12 or younger, and to write as full a description as they can of the event or memory. If they can only remember a portion, then just write what they can remember. Ask them to record all the feelings, actions, people present, and other thoughts they remember at the time. Allow about 15 minutes for this writing. Approximately three minutes before the time is up, tell them that they have three minutes to finish. Have each member report on what they wrote. They can summarize or give a brief description of what they wrote. The leader needs to allow enough time for every member to report, so do not deepen the experience of a member, or explore what emerged at this time. If time permits, you can return to do some exploration. In any event, if it is significant for the member, he/she will bring it up again in another session. Ask members what feelings emerged as they wrote about the event or memory, and what feelings do they have now.

Activity 5.7 A Teen Event or Memory Materials Sheets of paper or a journal, and writing instruments. Procedure Introduce the activity as described in activity 5.6, substituting “teen event or memory”. Follow steps 1–4. Activity 5.8 An Adult Personal Event or Memory Materials Sheets of paper or a journal, and writing instruments. Procedure Introduce the activity as described in activity 5.6, substituting “an adult personal event or memory”. Follow steps 1–4 in activity 5.6. Activity 5.9 An Adult Work-Related Event or Memory Materials Sheets of paper or a journal, and writing instruments.

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Procedure Introduce the activity as described in activity 5.6 substituting “an adult work-related event or memory”. Follow steps 1–4 in activity 5.6.

Session Writing – Free Associations The next set of activities focuses on free associations. While five topics are suggested, group leaders can use the procedures to focus the group on what they are avoiding, resisting, or other important issues for the particular group. The five topics are the group, life satisfactions, life dissatisfactions, a wish, and my relationships. The materials and procedure will be the same as described for “The Group”. Activity 5.10 The Group Materials A suitable writing surface, pen or pencil, and paper. Procedure Introduce the activity by telling members that there are times when thoughts and feelings seem difficult to express. At other times, there are numerous thoughts and feelings being experienced so that it is difficult to sort through them. This activity will demonstrate how to do free association to make sense of difficult thoughts and feelings, or when they seem too numerous. 1 2

3 4 5 6

Present the topic or issue that they are to write about, e.g. the group. Ask members to list all of the thoughts, feelings and ideas that come to mind when they think of the topic or issue, and to do so without stopping to evaluate or judge what comes to mind. Write as many of these as they can in the time given. Allow at least five minutes for writing, but some groups may need a little longer. The next step is to review their lists and place a check by all the thoughts, ideas, and feelings that are negative. Next, place a check by all that are positive. Count the number of positives, and the number of negatives. Make a note of the number of neutral thoughts, feelings, and ideas that remain. Ask each member to report the number of positives, and the number of negatives. The leader should pay attention to members who seem to have the majority of positives, and those that have a majority of negatives. Do not comment on these at the time. You are compiling the responses for

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the group as a whole response. When the compiling is complete, the thoughts, feelings, and ideas members have about the topic or issue should be either predominately positive, or negative, or neutral. Lead a discussion about the outcomes, and solicit members’ input on what is contributing to the perceptions and responses, and, if negative, what can be done to make it more positive.

Activities 5. 11–5.14 Use the same materials and procedures in activity 5.10 to explore each of the following. Activity Activity Activity Activity

5.11– 5.12– 5.13– 5.14–

Life satisfactions Life dissatisfactions A wish My relationships

Session Writing – Letters The next set consists of activities focused on the inner self of group members. These can be done as a way of taking inventory of how each member feels about him/herself, to increase awareness of self-satisfactions with oneself, and to increase awareness of the need for self-care around a major part of oneself. It is suggested that an activity focused on one aspect of self be completed in a session. Thus, the six activities presented could be the focus for six sessions. The set of activities are letters to aspects of the inner self of the person. The aspects are cognitive, interpersonal, emotional, creative, inspirational, and physical. Each is presented separately as the focus for each aspect is different. Activity 5.15 Letter to my Cognitive Self Materials A suitable surface for writing, a pen or pencil, and paper – several sheets for each person. Post the following where members can see it: The Cognitive Self Thinking Organizing Clarity Memory If members and the leader agree, the writing can be done on the computer.

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Procedure Introduce the activity by telling group members that the focus will be on writing a letter to their inner selves, and the first letter will be to their cognitive self. The cognitive self is the mind, the mental life of the person. 1

2 3

Begin the letter with, “Dear Cognitive Self”, and write what you are thinking, sensing, and feeling about each listed aspect of the cognitive self. Write about what you appreciate, wish were different, any regrets, and close with “thanks for being there”. Allow 15–20 minutes for letters to be composed. If members need more time, give one to two minutes and tell them they can finish after the group. Ask members to read their letters if they wish, or any part. Notice similarities among the letters, and link these for members.

Activity 5.16 The Interpersonal Self Materials Same as above, except post the following. The Interpersonal Self Relations with family Intimate relationships Work relationships Other relationships The Interpersonal Self is the ways in which you relate to others, and your satisfaction with your relationships. Procedure Follow the same procedures for the Cognitive Self, substituting the Interpersonal Self. Activity 5.17 The Emotional Self Materials Same as above, except post the following. The Emotional Self Feelings experienced Feelings easily expressed

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Feelings difficult to express Feelings you are unable to access – never feel them The Emotional Self focuses on the extent to which you can access and express feelings, and if you are able to appropriately express your feelings. Procedure Follow the same procedures for the Cognitive Self, substituting the Emotional Self. Activity 5.18 The Creative Self Materials Same as above except, post the following. The Creative Self Imaginative New and novel endeavors, processes, and the like Unique ways of being and perceiving The Creative Self emphasizes trying new and novel ways for different aspects of your life. Examples are cooking, gardening, fixing things, artistic endeavors, inventions, and the like. Procedure Follow the same procedures for the cognitive self, substituting the creative self. Activity 5.19 The Inspirational Self Materials The same as above, except post the following. The Inspirational Self Altruistic acts Hopes Meditation, prayers, and the like Transcendent The Inspirational Self is the part of you that extends beyond the physical and known. It connects you to the universe and to others.

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Procedure Follow the same procedures for the Cognitive Self, substituting the Inspirational Self. Activity 5.20 The Physical Self Materials The same as above, except post the following. The Physical Self Health habits Health status Medical conditions and concerns Appearance The Physical Self refers to the body, both inner and outer, its care or neglect, and sensations. Other topics that may be addressed include medications, use of other drugs and alcohol, eating habits, sleep, and physical exercise. Procedure Follow the same procedures for the Cognitive Self, substituting the Inspirational Self.

Session Writing – Dreams Dreams can be a rich source of information for group members as these can tap into what is below awareness of the person’s current life, provide a focus for what appear to be indefinite concerns, and bring feelings into awareness. What follows is not dream analysis, as would be done in psychotherapy, but is a short activity that can trigger insight and awareness for group members. Activity 5.21 A Dream Materials A suitable surface for writing, pen or pencil, and two or more sheets of paper for each member. Procedure Introduce the activity by telling group members that sometimes a dream has a message for the dreamer, and that this activity could help reveal the message.

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1

2 3 4 5

Ask members to think of a dream or fragment of a dream, either recent or in the past, and to write a summary of the dream. Allow time to complete the summaries. The next step is to have members read over the summaries, and list the feelings associated with the dream, either then or in the present. Ask group members to make a list of the major components in the dream – people, actions, colors, whatever seems important to them. The final step is to review the two lists and associate the items with their current lives. It is helpful to have them write a statement about the associations. Group members can share any part or all of what was written, but time must be available for every member to share something. Group leaders could just have members share the final statement about their associations.

Session Writing – Lists Each of the following activities can be completed in a single session, but the effects can be enduring and material that emerges during the activity can reemerge in later sessions. It is recommended that only one of these be used in a session. Activity 5.22 The Power of Lists Materials 5”  8” index cards, a pen or pencil, and a suitable writing surface. Procedure 1

Distribute the materials and introduce the activity. Oft times some people tend to focus more on their characteristics that they perceive as inadequate, or negative. There are also times when others can say or do something that triggers these undesirable thoughts about oneself, leading to experiencing uncomfortable feelings like guilt and shame, or seeking to repress and deny the thoughts for fear of triggering those feelings. This activity is designed to focus on your strengths, and to provide you with a reminder of these.

2 3 4

Ask members to list ten strengths they have, such as being well-organized and the like. Allow enough time for members to finish their lists. Next, ask them to share their lists with the group, or to share as much or as little as they desire. After the sharing phase, explore the lists by asking the following:



What feelings did you experience as you created your list? What feelings emerged as you presented these strengths to the group?

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Are there strength similarities among group members? Is there a strength you have that is underused? How could you capitalize more on this strength?

Tell group members to keep their cards in a safe place, and to review them periodically, such as weekly. Tell them that this strength list can be used when they begin to have self-doubts, feel inadequate, or are chastised for something. The list can help bring thoughts and feelings back to their strengths.

Session Writing – Self-Affirmations Activity 5.23 Life Enhancers Materials A sample list of life enhancers on newsprint, 5”  8” index cards, and a pen or pencil. Procedure 1

Prepare the sample list of personal life enhancers. These are the things, events, and the like that bring pleasure, make you smile, and can help you savor your life. These are usually cost-free or inexpensive. Following are examples. Kittens playing A child smiling at me Snow gently falling A snow-covered landscape A fire in the fireplace A drink of water on a hot day Flying a kite Reading an interesting book

2 3 4 5 6

Introduce the activity by presenting the prepared list and telling group members the information in step 1. Ask group members to make their personal lists of life enhancers. When members finish their lists, ask them to share these in the group. Explore the feelings aroused as they created their lists, as they shared their list in the group, and as they listened to others’ lists. Summarize what transpired and tell them that they have many life enhancers, and that their pleasure and positive mood can be increased by trying to ensure that they experience one or more of these every day.

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Activity 5.24 Self-boosters Materials A large sheet of newsprint, 5”  8” index cards, a pen or pencil, and a prepared sample. Procedure 1

The group leader should prepare a sample in advance, either on the large sheet of newsprint, or written on a whiteboard, or something similar.

SAMPLE

Finish the statement that begins with, I have … Good work habits An optimistic attitude A sense of humor A capacity to feel deeply A thirst for knowledge and understanding 2

Introduce the activity to group members by telling them that it can be helpful to remind themselves of some positive attributes they possess. Show the sample and ask them to make their personal lists on the card. 3 Once members have completed their lists, have them read the list out loud as if they are talking to someone in another room, that is read it loudly. They can even shout if they like. 4 After all lists are read out loud, explore the feelings experienced as they compiled their lists, and as they loudly read them. Be sure to ask if anyone had difficulty in thinking of a self-booster. Activity 5.25 A Letter Materials Two or more sheets of paper for each group member, and a pen or pencil Procedure 1

Distribute the materials and introduce the activity. This activity is focused on self-care and your satisfaction with what you do to take care of yourself. This particular activity is focused on physical self-care, but you can use this process to explore your self-care for other aspects of yourself. To begin, sit in silence and

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concentrate on your breathing. Slowly, allow yourself to become aware of what bodily sensations you have. Mentally scan your body from head to toe. 2

3

4 5

Tell members to begin their letters with “Dear (their name)”, and write about their current body experiencing, and its reaction to their positive and negative health habits, such as sleeping, eating, exercise, medication/ drug use, and so on. Write what your body wants to tell you about how you care for it. If any part of your body is distressed, write what you think it is saying to you. Tune in to all of your body and write about what its message is. When members seem to have completed their letters, ask them to review the letters, and then write a summary statement about their body. For example, what did they become aware of that is positive or negative? What may they have ignored about their physical self that needs attention? Ask them to share their summaries or their letters. They can share as much or as little as they are ready to disclose. Explore the feelings about the activity.

Journaling The final type of writing activity to be presented is journaling. Journal writing is another form of expressive writing as it also uses this format for the exploration of oneself for better understanding, healing, and fostering growth. It has been shown to have both psychological and physical benefits (Lepole & Smyth, 2002). One of the main benefits for journal writing is that it can be used for expressing thoughts, feelings, and ideas, where doing so interpersonally is not possible, or the circumstances are inappropriate to do so. Further, journaling permits for expression free from the constraints of grammar, logic, sequencing, and the like that are needed when trying to express these to another person. Much has been written about the benefits of journaling in the past few years, and with the research on expressive writing as a brief form of journaling, there is considerable evidence for its efficacy. The benefits for journaling seem to be considerable, for example as a stress reliever, clarifying thoughts and ideas, expressing and sorting through feelings, identifying vague issues and concerns, and so on. Other benefits include enhancing creativity and releasing the flow of new ideas, an aid to coping with stressful events by using energy to express reactions instead of having to suppress them, and as a record of life events both positive and negative. People who use this modality report many positive benefits. There are numerous studies on the effects of written emotional expression on physical and psychological health conditions – for example, Smyth, 1998; Smyth et al., 1999; Spiegel, 1999; Walker et al., 1999). One study on emotional writing and psychological symptoms that compared writing and drawing about

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a stressful event found that the psychological symptoms were significantly decreased after two 15-minute sessions for the journaling group compared to the drawing and control groups. This was especially significant for the journal group participants who had measured higher psychological distress on the pretest. A sample of other studies on the moderation of psychological distress and/or traumatic events includes Lumley et al., (2002); Pennebaker, (1999); Pizarro, (2004); Ullrich and Lutgendorf, (2002); and Sweig, (2000). Other uses for journal writing are in the medical training profession to promote reflective thinking, and to explore and integrate experiences with patients. Four examples of this use are: using reflective writing as a class blog, (Chretien et al., 2008); reflective journals for learning for post-registration nursing students (Chirema, 2006); medical students (Wald et al., 2010); and for medical students experiencing the death of patients (Doll et al., 2008). Other professional training programs also use journal writing such as the following:







Veterinary clinical pathology (Sharkey et al., 2007) Dental hygiene (Hanson & Alexandar, 2010) Emergency psychiatry (Bhuvaneswar, 2009) Physiotherapy (Donaghy & Morss, 2007) Athletic training education (Mensch & Ennis, 2002) Animal science and dairy science (Haug, 1996)

The group leader must be prepared for some resistance when asking members to keep journals over a period of time. There are people for whom journaling does not provide relief, but rather presents them with a burden and chore which counter any possible positive benefits. Further, some group members can resist journaling because of past experiences where their writing was criticized or evaluated as inadequate, or they think that their technical writing skills such as spelling and punctuation are inferior, or they do not want others in their world to see their writings and privacy is a real concern, or they just don’t see any benefits for writing a journal. These are some reasons why journaling may not be acceptable for some group members, and the group leader needs to respect and accept these perceptions and to not insist that members participate even when the leader feels that participating would be beneficial. Before initiating this activity, it is helpful to judge the level of the resistance because it is not beneficial for the group when some members are participating, and some are not. Let’s suppose that the group leader has some members who want to do journaling, some who are skeptical, and some who are adamant about not participating. Instead of forcing the activity as conceptualized, or dropping it entirely, the leader could try one of the following activities as a way to ease members into journaling.

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Activity 5.26 Building Pleasure Materials A journal book or composition book. These are generally inexpensive and can be found in many craft stores for a dollar. The leader can purchase these for the group. Also needed is a pen or pencil for each member. Procedure 1

Introduce the activity by telling members that it is helpful for their mood, to be able to focus on pleasurable and personally rewarding things each day. The journals are to record the following each day between sessions:





2 3 4

A pleasant sight, such as flowers blooming, children playing, a smile directed toward them, and the like A pleasant sound, such as music, car engine running smoothly, birds singing, and so on A pleasant smell – food, perfume, fragrant flowers, lotion, soap, and the like A pleasant taste – coffee, fruit, toothpaste, candy, and the like

They are also free to record anything else that was pleasant for them. The first phase or week they would talk about their recorded items if they choose to, or how it felt to remember and record these. The leader can gradually ask for more associations, such as feelings experienced for each recorded item, difficulties encountered, impact on their mood and functioning. Members could also be encouraged to write these in the journals as they record their experiences, but the leader should present this as an option.

Activity 5.27 Home Contents Materials Same materials as in the previous activity. Procedure Introduce the activity as was done previously substituting writing about something in their home. If there are homeless group members, substitute writing about something that gives them a feeling of home. Items could be a piece of furniture, an article of clothing, a book, magazine, food, or anything they choose.

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1

Select one item each day and write about it addressing each of the following:




Describe the item’s appearance, color, shape, etc. List the feelings triggered as they look and/or write about the item A short statement about what the item contributes to their life

Other Types of Journals Journals are a record of thoughts, feelings, and ideas experienced daily, weekly, or intermittently. There is no set pattern of what to write or when, it’s up to the individual. Some people like to write daily, others want to write when they have something to work out, convey, or to record. It’s really up to the individual. Used this way in group settings, it becomes homework where members are free to participate or not, to disclose what they wrote or not, or to reveal to the group the insights and learning they gleamed from journaling. It can be very important that members have some place where they can keep their journal private and free from intrusions. It can be very detrimental to a relationship to have one’s private thoughts read by someone else without permission, and when you live with others, this is a real possibility. Curiosity can overcome even the most well-meaning person when they see the journal. If privacy and confidentiality of the journals cannot be maintained by the members, it may be best not to use this technique. What can members write about and how should they express themselves? There is no simple or easy answer to these questions. The group leader can give a focus topic such as those listed as the end of this section, or allow members to choose what to write about, or if there is a particular goal or behavior change that is the focus for the group, to write about that. The group leader can instruct members to write however they wish. They can write poems, prose, a stream of consciousness, words, phrases, or what occurs to them as they engage in the process of writing. No one is evaluating what they write, grammar and punctuation are of no consequence except for the writer, and the purpose is more to express something than how it is expressed. Encourage members not to engage in self-evaluation or editing, to just let the flow of thoughts, ideas and feelings continue without interruption of thinking about technical matters. Some possible topics or foci for journals include the following:






Daily thoughts and ideas Feelings experienced throughout the day, and their triggers What it’s like to practice mindfulness Current worries and concerns Hopes, dreams, wishes

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Visual Journaling A variation for journals is the visual journal where drawings, painting, collage, etc. are added to the written words. There can be doodles, tracings, rubbings, and other images that are added to the thoughts, feelings, and ideas that are expressed in the journal. These enhancers also are expressions, and can be clues to what is just below the level of consciousness at that particular time. When reviewed later, these entries can help the person to better understand past experiencing and its impact on him/her. Following is an activity for a sample visual journaling page. Activity 5.28 A Sample Visual Journal Page Demonstration Preparation by the leader Prepare a variety of pages (8½”  11” or 9”  10”) to be used as background for the visual journal pages using heavyweight paper such as Bristol or watercolor paper. These background pages can be painted or smudged with ink pads. Use a variety of colors. These are prepared in advance to save time in the group, as they need time to dry before adding writing or other embellishments. Materials Scissors; magazines or catalogues for cutting out images; pen or pencils for writing; glue sticks; sheets of paper; permanent black ink felt markers in fine, medium, and broad points; and sets of crayons, or felt markers, or colored pencils. Procedure 1

2

It is best that the group work around a table so that materials can be shared and easily accessed. Introduce the activity by telling members that this is a demonstration for a visual journal entry about their day. Ask them to reflect on their day from the time they woke up to the present. Ask members to take a sheet of paper and a writing instrument, and jot down five to seven items about their day such as the following:







Moments of pleasure or beauty Thoughts they had throughout the day Sounds/tastes/sensations experienced Events People they encountered Feelings experienced

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They can list all items in one category or spread across categories. These lists will be used to form the written entry for the page later. 1

2

3

Next, ask them to select a prepared journal page, and to cut out images from the magazines or catalogues and paste on the page, and/or draw images, doodle on the page, or use a combination of collage and drawing. Remind members to leave room for their written entry. The next step is to write about the items listed in step 2. Use the permanent felt pen for writing as these will write over the paint or ink. Members can write as much or as little as they wish, sentences do not have to be complete, and there are no rules about punctuation. The task is to write about their day. Once pages are complete, reconvene the group and ask members to share something about their pages and the feelings experienced as they constructed the page.

References Ames, S. C., Patten, C. A., Werch, C. E., Schroeder, D. R., Stevens, S. R., Fredrickson, P. A., & Hurt, R. D. (2007). Expressive writing as a smoking cessation treatment adjunct for young adult smokers. Nicotine & Tobacco Research, 9(2), 185–194. Barry, L., & Singer, G. (2001). Reducing material psychological distress after the NICU experience through journal writing. Journal of Early Intervention, 24, 287–297. Batten, S., Follette, V., & Palm, K. (2002). Physical and psychological effects of written disclosure among sexual abuse survivors. Behavior Therapy, 33, 107–122. Bhuvaneswar, C., Stern, T., & Beresin, E. (2009). Using the technique of journal writing to learn emergency psychiatry. Academic Psychiatry, 33(1), 43–46. Brown, E., & Heimberg, R. (2001). Effects of writing about rape: Evaluating Pennebaker’s paradigm with a severe trauma. Journal of Traumatic Stress, 14, 81–85. Bucci, W. (1995). The power of the narrative: A multiple code account. In J. Pennebaker (Ed.), Emotions, disclosure and health. (pp. 93–123). Washington, DC: American Psychological Association. Chan, K., & Horneffer, K. (2006). Emotional expression and psychological symptoms: A comparison of writing and drawing. The Arts in Psychotherapy, 33(1), 26–36. Chirema, K. (2007). The use of reflective journal in the promotion of reflection and learning in post-registration nursing students. Nurse Education Today, 27(3), 192–202. Chretien, K., Goldman, E., & Faselis, C. (2008). The reflective writing class blog: Using technology to promote reflection and professional development. Journal of General Internal Medicine, 23(12), 2066–2077. Doll, K., Kereakoglow, S., Radhika, S., & Hare, J. (2008). Using students’ journals about death experiences as a pedagogical tool. Gerontology Geriatric Education, 29(2), 124–138. Donaghy, M., & Morss, K. (2007). An evaluation of a framework for facilitating and assessing physiotherapy students’ reflection on practice. Physiotherapy Theory and Practice, 23(2), 83–94.

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Esterling, B., L’Abate, L., Murray, E., & Pennebaker, J. (1999). Empirical foundations for writing in prevention and psychotherapy: Mental and physical health outcomes. Clinical Psychology Review, 19(1), 79–96. Gortner, E., Rude, S., & Pennebaker, J. (2006). Benefits of expressive writing in lowering rumination and depressive symptoms. Behavior Therapy, 37(3), 292–303. Hanson, K., & Alexander, S. (2010). The influence of technology on reflective learning in dental hygiene education. Journal of Dental Education, 74(6), 644–653. Haugh, M. (1996). How to incorporate and evaluate writing skills in animal science and dairy science courses. Journal of Animal Science, 74(11), 2835–2842. Koopman, C., Ismailji, T., Holmes, D., Classen, C., Palesh, O., & Wales, T. (2005). The effects of expressive writing on pain, depression, and posttraumatic stress disorder symptoms in survivors of intimate partner violence. Journal of Health Psychology, 10, 211–221. Lepore, S., & Smyth, J. (Eds.). (2002). The writing cure. Washington, DC: American Psychological Association. Lumley, M., Tojek, T., & Macklem, D. (2002) The effects of written emotional disclosure among repressive and alexithymic people. In S. J. Lepore, & J. Smyth (Eds.), The writing cure: How expressive writing promotes health and emotional well-being. Washington, DC: American Psychological Association. Mensch, J., & Ennis, C. (2002). Pedagogic strategies perceived to enhance student learning in athletic training education. Journal of Athletic Training, 37(4), S199–S207. Oatley, K., & Djikuc, M. (2008). Writing as thinking. Review of General Psychology, 12(1), 9–27. Park, C., & C. Blumberg (2002). Disclosing trauma through writing: Testing the meaning making hypothesis. Cognitive Therapy and Research, 26, 597–616. Pennebaker, J. W. (1997a). Opening up: The healing power of expressing emotion. New York: Guilford. Pennebaker, J. W. (1997b). Writing about emotional experiences as a therapeutic process. Psychological Science, 8, 162–166. Pennebaker, J. (1999). Psychological factors influencing the reporting of physical symptoms. In A. A. Stone, J. S. Turkan, C. A. Bachrach, J. B. Jobe, H. S. Kurtzman, & V. S. Cain (Eds.), The science of self-report; Implications for research and practice. (pp. 299–316). Mahwah, NJ: Erlbaum. Pizarro, J. (2004). The efficacy of art and writing therapy: Increasing positive mental health outcomes and participant retention after exposure to traumatic experience. Art Therapy, 21, 5–12. Reisman, A.Hansen, H., & Rastegas, A. (2006). The craft of writing: A physician-writer’s workshop for resident physicians. Journal of General Internal Medicine, 21(10), 1109–1111. Richards, J., Beal, W., Seagal, J., & Pennebaker, J. (2000). The effects of disclosure of traumatic events on illness behavior among psychiatric prison inmates. Journal of Abnormal Psychology, 109, 156–160. Robinson, M. (2000). Writing well health & the power to make images. Journal of Medical Ethics: Medical Humanities, 26, 79–84. Sharkey, L., Overmann, J., & Flash, P. (2007). Evolution of a course in veterinary clinical pathology: The application of case-based writing assignments to focus on skill development and facilitation of learning. Journal of Veterinary Medical Education, 34 (4), 423–430.

118 Writing Activities Sloan, D. M., Marx, B. P., & Epstein, E. M. (2005). Further examination of the exposure model underlying the efficacy of written emotional disclosure. Journal of Consulting and Clinical Psychology, 72, 165–175. Smyth, J. (1998). Written emotional expression: Effect sizes, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology, 174–184. Smyth, J., Stone, A., Hurewitz, A., & Kaeli, A. (1999). Effects of writing about stressful experiences on symptom reduction in patients with asthma and rheumatoid arthritis. Journal of the American Medical Association, 281, 1304–1309. Spera, S., Buhrfiend, E., & Pennebaker, J. (1994). Expressive writing and coping with job loss. Academy of Management Journal, 37, 722–733. Spiegel, D. (1999). Healing words: Emotional expression and disease outcome. Journal of the American Medical Association, 1328–1329. Sweig, T. (2000). Women healing women: Time-limited, psychoeducational group therapy for childhood sexual abuse survivors. Art Therapy, 17, 255–264. Ullrich, P., & Lutgendorf, S. (2002). Journaling about stressful events: Effects of cognitive processing and emotional expression. Annals Behavioral Medicine, 24, 244–250. Verghese, A. (2001) The physician as storyteller. Annuals of Internal Medicine, 135, 1012–1017. Wald, H., Reis, S., Monroe, A., & Borkan, J. (2010). The loss of my elderly patient: Interactive reflective writing to support medical students’ rites of passage. Medical Teaching, 32(4), e178–e184. Walker, B., Nail, L., & Croyle, R. (1999). Does emotional expression make a difference in reactions to breast cancer. Oncology Nursing Journal, 1025–1032.

Chapter 6

Physical Movement Dance, Physical Exercise, Performance

Introduction This chapter focuses on releasing the wisdom, knowledge, creativity, and emotional life of the body. Within the physical self are connections to the other aspects of self that can be unavailable to the conscious. Some are nonconscious material just below the level of consciousness, while others are unconscious. Tuning into what one’s body knows and understands brings meaning and relevance to much of what is experienced by other parts of the self; or, this information can be used to reconnect to that part of oneself which may have become repressed or split off from conscious awareness. This can be very deep therapeutic work and is not the focus for this chapter as that use calls for well-trained therapists in the particular modality of body work as well as training in the therapeutic use of this work in groups. What is presented here are physical movement activities that group leaders can use that can enhance the therapeutic process without necessarily triggering deeper nonconscious or unconscious material. The activities presented here are primarily used for tension relief, to play and have fun, to focus on one’s body and increase awareness of its present functioning, and to demonstrate an access to one’s creativity. Presented here are movement, dance, physical exercise, and drama/performance activities, such as improvisation and role play.

A Rationale – the Mind-Body Connection The work and research on the mind-body connections provide a rationale for inclusion of physical activities in group therapy even when the primary focus and emphases are on other issues and concerns. Although the group leader may not be trained in a particular modality, such as dance therapy, there are occasions where a simple movement activity could be of benefit to the group and to members, and this is the intent of what is presented here. Evidence for mind-body influences are derived from three sources (Goleman & Gurin, 1993): DOI: 10.4324/9781003251989-6

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Physiological research on biological and biochemical connections between the brain and body. Exciting new findings are emerging through studies on neurobiology that is clarifying how and why these connections play an important role. Epidemiological studies that focus on the associations and connections between psychological factors and illnesses in the general population. Clinical studies to test the effectiveness of mind-body approaches to prevent, alleviate, or treat diseases and conditions.

A short example activity may help clarify what is meant by the mind-body connection. Activity 6.1 Mind and Body Materials A sheet of paper and a pen or pencil Procedure 1

2

Find a place to work where you will not be disturbed and that has an appropriate writing surface available. Reflect or think about how you physically and mentally feel at this time. Write a short descriptive response to each of the following: a b c d

3

Your Your Your Your

current mood current mental/cognitive state current body status, e.g. aches, tensions, arousal, etc. feelings, e.g. sad, angry, pleased

Next, list a description or response for each of the following for the previous 12–18 hours in your life. Write in as much detail as possible. a b c d e f g h

Food and drink consumed The quality of your sleep Recreation/leisure Physical exercise activities, e.g. walking, working out at the gym, etc. Medications taken, e.g. prescribed, over-the-counter medication, etc. Vitamins and minerals taken Physical and medical conditions, e.g. allergies, menopause, high or low blood pressure Work and/or school-related activities and/or situations

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Next, review your current status and your previous 12–18 hours’ activities. Reflect on how your previous activities are impacting your current mood, cognition, body, and feelings. The following questions can guide your reflection: a b c d e f

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Were you able to eat healthy foods? Did you obtain sufficient and good quality sleep? Was there an opportunity to exercise or move your body? How many pleasurable activities did you experience? If you have a condition or symptoms that require medication, how much did the medication control these? Did you feel stressed or overwhelmed, or were you relaxed and comfortable?

Finally write a summary paragraph about the relationship of your body care in the previous 12–18 hours to your current physical, cognitive (mental), and emotional state or mood; and vice versa that is, how were your previous mental and/or mood states influencing your mental state.

Taking time to reflect on your body and mind interrelationship, influences, and other connections can demonstrate the viability and strength of the relationship, and serve as a reminder of just how much can take place on the nonconscious and unconscious levels.

General Guidelines Any movement group activity has the potential to arouse intense feelings and the group leader should stay aware of this potential when planning and conducting such activities. Even ordinary physical activities such as walking across the room, may trigger these feelings because of fears about being judged and evaluated, and the group setting produces a venue for observation by others, which provides opportunities for judgments and evaluation by others. Members can fear that they will be found to be inadequate in some way and thus, shamed. Childhood memories of being taunted and teased about athletic ability or its lack, how one walks and/or their appearance when moving, looking funny or weird when dancing, one’s agility, and the like can easily be triggered by thought of a movement exercise in the group setting, and can be a source of resistance for movement activities. Further, if there is a history of body-related trauma such as rape, physical abuse, or multiple surgeries; fears and other emotions around the event(s) may be aroused even when the person may have deeply repressed such memories. The leader may not be aware of this history either because the type of group may not require this kind of information as part of screening or group assignment, or because the member does not remember it or chooses to not reveal it, or other such reasons. However, these events do continue to exert their influences. Ensuring the safety of group members when

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group leaders may lack information about their past experiences and/or unresolved issues underlies the following guidelines. Plan the activity based on group needs. It seems elementary to plan the activity based on group needs, but there may be times when you as the leader just want to do something spontaneously, or you think such an activity will be “good for the group”. Those may be appropriate, but they are more likely to be your needs, and not that of group members. There should be a specific goal or purpose for the activity.














Before using a movement activity, describe to members what they will be asked to do and the goal and purpose for the proposed activity. Introduce the activity in as much detail as possible so that members can give informed consent for their participation. Doing so will help prevent unanticipated distress, deep memories being accessed, intense feelings aroused that may be uncontrollable for the person, and other such negative outcomes. Use activities that are group focused and not just for a specific person or subgroup. Movement activities, like other activities described in this book, are intended for the entire group, and leaders should take care that the chosen activity does not address what the leader feels a particular member or subgroup needs. They may benefit, but the focus should be on the entire group. This is also why I do not recommend that most activities be performed in dyads and triads. Members may work independently for some activities, but these are then shared and discussed in the whole group. Restrict or avoid movement activities that involve touching as this can be very scary and threatening for some group members even when they think they can handle it. It is almost impossible for a group member to know if touching others or being touched by others will trigger negative emotions based on past experiences, but that remains a definite possibility. Using activities that involve touch are risky and not recommended. Avoid activities that could trigger claustrophobic feelings, such as blindfolds. There are several trust activities that call for one person in a dyad to depend on another person and one such exercise involves blindfolding a person and guiding him/her on a walk. In addition to such exercises not being recommended because it breaks the group up into dyads, there is the possibility that something like a blindfold could trigger claustrophobia, where the leader did know of that possibility, the member did not know having never experienced being blindfolded before, or for a whole host of other reasons. There are many other activities that could be used to accomplish the same goals. Respect any and all resistance and reluctance to participate. Discussing the feelings aroused by thoughts about the proposed activity may be more productive. It is strongly recommended that group leaders respect any

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and all resistance and reluctance to participate in a movement activity. Holding a discussion about the feelings triggered by the thought of such an activity could be much more fruitful than pressing ahead with it. Provide clear and specific directions and check to ensure members’ understanding. Most movement activities give all of the directions at the front end, and group members can get confused about what they are supposed to do. To cut down on this confusion, the group leader should ensure that the directions are clear, and to answer any questions members may have. Block comments by other group members about a member’s appearance, agility, and the like. Keep the focus on the purpose for the activity. It is essential that any comments be blocked that could be received as taunting, teasing, derogatory, or demeaning. The speaker may be trying to joke, but these are the type of comments that can hurt and cause narcissistic injury.

Movement Movement can be energizing as well as providing a means to tune into the body. Purposeful moving is described more fully in the sections on dance, physical exercise, and role play. Movement here is simply to have group members participate in a movement of some sort, and then reflect and discuss what emerged for them as they moved. Topics that can be explored include feelings experienced, thoughts that emerged, awareness of bodily sensations especially pain and tension, and how they feel after the movement. Following is a short list of some movements that can be easily done in a session with reporting and exploration, that most if not all members are capable of performing, that are relatively non-threatening, and can be energizing. The group leader should, of course, ensure that all group members can participate in the particular movement before introducing it as an activity.





Move around the room without talking, and make eye contact with every group member Skip, jump or hop around the room Line up according to birthday, from January 1 Practicing sports signals: touchdown, safe and out in baseball, walking in basketball, etc.

Activity 6.2 Speedy Introductions Materials None

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Procedure 1 2

Divide the group into dyads and label one dyad A, and the other dyad as B. Have each dyad sit facing each other. Instruct them to do the following:





3

4

Each person in dyad A will talk to B for one minute, introducing him/ herself. At the end of the minute, the leader calls time, and each A person will move one seat to the next B person and repeat the introductions. This continues until every A has had an opportunity to introduce him/herself to every B. The procedure is repeated so that every B now has an opportunity to introduce him/herself to every A. The next step is to divide the A’s into dyads, and do the same for the B’s. They now speed introduce themselves to each other with all A’s introducing themselves to other A’s, and B’s doing the same.

Reconvene the group and explore what feelings emerged as they did the introductions, the listening, and the movement. What kind of information was shared in the introductions? Ask members to identify any similarities among other group members as they were introduced.

Dance Dance is defined here as a rhythmic movement usually accompanied by music. Dancing can be solitary, with a dance partner, or as a group activity, such as line dancing. Dance can tell a story, for example, ballet; convey nonverbal messages such as in many South American dance forms; tune into spiritual matters such as some Native American dances; and as a means of expressing emotions and other abstractions such as with modern dance performances. When used in therapy, dance can become an access to unknown and maybe unacceptable parts of oneself, repressed and/or denied memories, a release of energy, and an expression of creative and inspirational forces. When used for these reasons, dance activities are the primary focus for the group, are used constantly in almost or in every session and may have a sequential structure, and the group assumes less prominence for therapy. As noted before, dance as therapy requires specialized training and is not the focus in this presentation. Recent literature on dance therapy addresses uses for diverse conditions and issues:





Body image (Langdon & Petracca, 2010; Swami et al., 2009) Medically unexplained symptoms (Payne, 2009) Parkinson’s disease (Hackney & Earhart, 2010) Emotionally focused couples therapy (Hazlett, 2010)

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Female perceptions of male strength (Hugill et al., 2009) Eating disorders (Alexandridis et al., 2007; Burn, 1987) Schizophrenia (Xia et al., 2009) The elderly (Alpert et al., 2009; Lima et al., 2007)

Dance is included in this chapter for information, and because it can be used in a group for reasons other than those noted above. This presentation views dance as an activity that can be used as a movement activity where appropriate for the following purposes:





To relieve tension and stress As a means to express current feelings To play and have fun Bring attention to the physical self and focus on its current state

Activity 6.3 Free-Form Dancing Materials Music and a music player. Procedure 1

2

Start the music and tell members to move around the room any way they want to. They can jump, skip, whirl around, do a dance step, and so on. Let them dance for ten minutes. Stop the music, ask members to return to the circle, and explore the experience of moving without direction or purpose. Ask for feelings experienced as they heard the directions, as they moved around the room, and now as they talk about it.

Activity 6.4 In Sync Materials Music and a music player Procedure 1 2

Pair off group members. While this is easier to do in pairs, triads can also be used. The pairs are to try to synchronize their movements (dance) without talking. One will take the lead to begin the steps, and each should take a turn in changing the movement, all without talking.

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3

4

Start the music and tell the pairs to begin moving. Allow 10–15 minutes for the dance, and observe how the pair performs, how much or how little in sync they are, and other body movements. Stop the music and ask them to return to the circle. Explore the feelings aroused by the experience, especially noting the feelings aroused by not being able to talk. Ask them how they communicated without talking, if it was difficult to become synchronized, and the extent of satisfaction with their performance. The leader should note any observations as indicated in step 3.

Activity 6.5 Just Walking Materials Musical selection that has a variety of tempos from slow to fast, and a music player. Procedure 1

2

Tell members that you are going to give them directions as they walk around the room, and ask that they become aware of the feelings aroused as you change the directions. (The leader can provide a demonstration of what will be the directions.) Start the music and take them through the following sequence of walks. Try to change the walk to fit the tempo of the music.




3

Plod – walk as if the legs are carrying a heavy weight, and each step seems to be an effort. Mosey – walk as if you don’t have a care in the world, have no time pressures, and are enjoying yourself. Stride – walk fast and confidently.

Reconvene the group, and explore the walking experience, with particular attention to feelings experienced with each kind of walk.

Physical Exercise The use of exercise (physical movements) in a group usually calls for the group leader to have expertise and may even call for certification in the particular form used such as yoga, in order to be most effective and to maintain appropriate boundaries. There can be many applications for an activity using physical exercise focused group such as the following.



Cancer survivors (Sherman et al., 2010) Veterans with comorbid psychiatric and medical conditions (Periman, 2010)

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Weight loss (Byom, 2010) Post-stroke fatigue Chronic pain in elderly adults (Ersek et al., 2009) Depression (Kunic et al., 2008) Risk of coronary disease (Hardcastle et al., 2008)

A physical exercise focused group is defined as one where the majority of time in a session is used for the exercise, and group discussion and interactions are less emphasized although this too is considered a vital component. These physical focused groups can generally have the following sequence: introductions/checkin; warm-up; focused activity or physical exercise for the session; cool down; and group discussion. This sequence requires that the leader is able to lead the physical exercise because having someone who is not a group member would be very disruptive to the process and may cause resistance to disclosure. Another way to use physical exercise as a focus would be to have members perform the physical exercises outside the group session, and then the group sessions would focus on members’ experiences as a stimulus for group discussions about sensations and feelings aroused, memories triggered, and other nonconscious and unconscious material. In some groups, the emphasis could be on the performance as an aid to the condition, such as that described by Kunik et al. (2008) for depression. Other groups may use members’ outside exercise experiences to address other psychological concerns such as body image (Byom, 2010). Both medical and psychiatric conditions may be addressed with this use of physical exercise, and the leader need not be an expert in the particular physical exercise. A third way to use physical exercise in the group would not have the exercise as a focus for the group session, call for members to perform these outside of the group, or need the group leader be an expert in the particular group modality. This kind of application simply uses an easily explained and implemented brief physical exercise as a stimulus for group discussion where the majority of the time would be spent on that. As with most all movement activities, members would be instructed to perform the activity only to the point where they remain comfortable, and to not strain themselves beyond this point. Possible reasons for use of brief physical exercises in the group are to focus on the body, use sensations to access feelings, relieve tension and stress, to energize, and to affirm health-enhancing behaviors. Activity 6.6 Increase Energy Note: be sure to consider the physical state of members before initiating this activity. Materials None. If music is used, then a recording and a player is needed.

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Procedure 1 2

3

Ask group members to stand and position themselves about four feet apart. Introduce the activity by telling members that you are going to lead them through a short set of body movements are designed to increase energy. The movements are easy, and tell them that they are to only do what is comfortable for them. Direct them through the following at a relaxed, easy pace:














4

Head – Stand and spread feet apart about 12 inches, stand straight with arms by their sides and knees slightly bent. Gently allow the head to move toward the right shoulder, hold for 2–3 seconds, bring the head back to center, and repeat for the left side. Do this slowly 4–5 times. Shoulders – Assume the same position as before. Raise both shoulders up to the ears, hold for 2–3 seconds, and then relax. Do this 4–5 times. Side stretches – Assume the same position as before. Slowly raise the right arm overhead, and lean toward the left, thus stretching the right side. Do the same for the left side. Repeat 4–5 times. Legs – Begin in the same position. If group members have difficulty doing this move when standing, they can sit and do it. Instruct them to raise their right knee up toward the chest, wrap their hands around the knee, and pull it slightly toward the chest. Hold the position for 5–10 seconds. Repeat the process for the left knee. Repeat the entire process 4–5 times. Thighs – Begin in the same position, hold arms out to side at shoulder height. Keeping the head up and eyes straight ahead, slowly bend forward at the waist and hold for 5–10 seconds. Bring body up to stand position and repeat the bend 4–5 times. Moving – Direct members to march around the room (music can be used). Allow up to 5 minutes for marching. After the marching, repeat the stretching exercises with only 2–3 repetitions instead of 4–5.

Reconvene, sit in the circle, and explore the experience with a focus on feelings before the routine, and feelings now as they sit in the circle.

Activity 6.7 To Relax Materials None

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Procedure 1 2

Ask members to rate their body tenseness at this time on a scale of 0 – not tense to 10 – extremely tense. This set of exercises can be completed standing or seated. Use the following sequence of movements:







Tell members to open their mouths as wide as they can, yawn, and make a noise. Repeat for 30 seconds. Next, tell them to stand if possible, and arch their backs while stretching their arms out to the side. Hold that position for 5–10 seconds, relax, and remain standing or seated, and repeat the move 4–5 times. The next movement can be done seated or standing. Ask members to sit or stand straight, bring their shoulders back as far as possible, hold the position for 5–10 seconds, or as long as they can, and then relax. Repeat 2–3 times. The final movement is in three parts:




3

Allow the arms to hang loosely at the side, either standing or sitting. Then, shake your fingers, hands, and arms for about 10 seconds. Repeat the same procedure for each leg separately. If seated, have members stand and shake their bodies for a few seconds. (This move is difficult to perform in a seated position.)

Ask members to again rate their body tension (0 – no tension to 10 – extremely tense). Explore the changes, if any, by asking where the tension was at the beginning, and where is it now. Ask if the tenseness or lack of tension make a difference in their mood, feelings, and the like.

Movement: Performance Activities We now turn to a more controlled use of the body, which also brings thoughts and feelings simultaneously into the experience, that of drama or performance activities. Benefits of drama/performance activities include the following:









Assists in breaking down social barriers between group members Promotes empathic understanding Reduces distancing and disassociation Increases emotional expressiveness Can be a means to demonstrate how to give and receive constructive feedback Emphasizes the mind-body-emotional connections Can help reconnect to unknown, disowned and/or fragmented parts of self Increase clarity of thinking

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Perhaps the best-known form of drama in therapy is psychodrama created by Moreno (1964), which is very action oriented to promote insight, creativity, and explore personal problems. While there are some strategies used in psychodrama that can be used without training, this technique requires considerable and specialized training, and is presented here only as an example. The main points for psychodrama are that spontaneity and creativity are encouraged, the work is done in the present regardless of when the condition, issue or problem occurred, exploring how connections are formed and maintained with others, what and how one is attracted or repelled by others, to discover unrealized or unknown viewpoints, promote catharsis, and the group provides reality testing. Psychodrama has three phases: warm-up, action, and reporting and exploration. Procedures from Psychodrama that have been translated to other theoretical approaches include role reversal, doubling where the auxiliary plays the protagonist’s inner self, soliloquy, the empty chair, and the mirror technique. There are several forms for drama therapy such as the following:











Interactive storytelling (Park, 2002) where the storyteller presents lines from a well-known story or poem and group members respond with their lines adding to the tale or poem. Dramatic play (Oon, 2010) that has three elements or phases: playspace, role playing, and dramatic projection. Video interpretation (Horwitz et al., 2010) where group members were trained in body and voice expression, then acted in a drama with professional actors that was taped, viewed the tape, and interpreted their own emotional expression in the performance. Narradrama (Dunne, 2010) is a blend of narrative therapy with drama therapy, and also uses other expressive arts such as music, poetry, and the visual arts. Story-making drama and body mapping (Meyer, 2010). Improvisational theater (Veenstra, 2010). Cognitive behavior drama (Karnezi & Tierney, 2009), which integrates principles and techniques from cognitive and behavioral therapies with drama. Psychodrama relapse prevention skills (Morris & Moore, 2009).

Drama therapy or dramatherapy encompasses numerous variations of performance, but only three will be presented here; role play, improvisation, and simulation or games.

Role Play Let’s define role play as assuming the role of another person as they are described, and participating in a prescribed scene to perform a situation or event. Benefits for this type of role play include the following:

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Insight can be enhanced Broader perspective gained Deeper and more empathic understanding of self and of others Ideas for alternatives and other possibilities generated Practice new behaviors Receive and give constructive feedback

Insight can be enhanced via role play because the participants have less intense emotional involvement as playing a role involves cognitive processes also. Further, when done in a group setting, there are also the variables and influences of being observed, possibly being evaluated, and concern about being found inadequate or becoming shamed that also combine to provide some distance. Insight is more possible as the person is able to see him/herself in a more objective way. The broader perspective can be provided by the feedback from the observing group members, leader, and other participants in the role play. Other’s perceptions have much less emotional involvement than would the generator of the role play, and that might give them other perspectives, and hearing these allows for a broader perspective to be adopted. Playing another person’s role can produce deeper and more empathic understanding of oneself and of others. Assuming a role requires that you think, feel, and act as you think the other person would, and that allows you to somewhat become as they are. Once you can get into the person, so to speak, you can better understand what that person is experiencing, which produces empathic understanding. Stepping back and observing, hearing the feedback from others in the role play, and from the observers will likely produce ideas for alternatives and other possibilities. Some ideas and alternatives may come from others, but the person generating the role play may now be able to see that there are other ways to perceive, manage, and act that may produce more satisfying outcomes. Role play is a wonderful opportunity to practice new behaviors, and to receive feedback on how these are perceived by others, as well as how it feels and fits to assume new ways of behaving. Behavioral rehearsal is a valid technique from Behavioral Therapy, and when there are others to participate, that enriches the experience as well as being able to practice new behaviors in a safe environment. The group can provide opportunities to give and receive feedback, and participating in a role play gives opportunities to practice how to make the feedback constructive. Usually the role play has some sensitivity, especially for the person generating the topic or scene for it, and group members are aware of this sensitivity, and can seek to provide important feedback but to also have it presented in such a way as to not hurt, insult, or offend.

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Guidelines for Role Play The following guidelines are for role play in a group setting where three or more members participate. Guidelines for dyads or triads are presented later. 1 2

3

4 5 6

7 8

Relationships among members, and safety and trust must be built and established prior to initiation of any role play activities in the group. The leader should determine the focus, goal, or problem that the role play is intended to address, and this should be at the group level so as to be immediately relevant for all group members. Examples of group level problems include shared difficulties in being appropriately assertive, conflict behavior, and confrontation. Introduce the activity and get members’ cooperation to participate. Have them write about or draw a situation or event that captures the essence of the focus for the role play, that is all members can have a personal involvement in the subject for the role play. After the writing or drawing, have members share their products, but do not explore or elaborate on these at this time. Ask one member to volunteer to have their scene as the role play. The member who volunteers becomes the director for the role play. The director selects the players, who do not have to play gender-specific roles, and briefs them on the scene. The group leader is briefing observers at the same time. Observers are expected to report on their feelings, thoughts, and what verbal and nonverbal behaviors they saw during the role play. The action scene takes place. The group leader then debriefs the director, the performers, and the audience, usually in that order. Example debriefing questions are as follows for each:








The director: ask about the accuracy of the performance, i.e. did the performers capture the essence of the director’s situation or event. Explore the feelings aroused as the director watched the performance. Finally, ask if the director has any new thoughts, ideas, or insights. Performers: ask each performer to report on what it was like for them to play the role? Was it difficult or easy? Did they find that they shifted back into being their selves? What were the feelings that emerged as they played the role? (Note: these can be reflective of the feelings of the other person(s) in the situation and may be new information for the director.) Audience/observers: ask them to report on the feelings, thoughts, and ideas that emerged as they observed.

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Exercise 6.8 A Negative Confrontation Materials Drawing: paper and a set of crayons, or colored pencils, or felt markers for each member. Writing: paper and a pen or pencil. Procedure 1

2 3 4 5 6

7

Distribute the materials and ask group members to think of a negative confrontation they experienced, either as the giver or receiver of the confrontation. They will be asked to draw or write about it first, and then one or more will be invited to role play the situation. A negative confrontation is defined as one where intense uncomfortable emotions were aroused and/or displayed, where there was not a consensual resolution, and/or where they left the interaction feeling dissatisfied or worse than when they began. Once they have thought of the experience, they are to either draw or write a description. When the writing or drawing is complete, reconvene the group and have members share their experiences. Do not explore at this time. Ask if a member wants to volunteer to have their situation role-played. Follow the guidelines for role play for the action and exploration phases. As a summary, ask the member whose situation was role played if they gained any additional awareness or understanding of the situation, and if there were additional steps that could have been taken to reduce the negative effects on either or both participants. If time permits, ask for another volunteer and repeat the procedure.

Simulations and Games Other forms of role play can be called simulations and games, and the new research that is emerging has revealed positive outcomes for neuroeconomic games. For example, Singer et al. (2005) found the Trust game to produce a greater understanding of the other’s perspective that was also observed for changes in brain activity. There was increased activation in the parts of the brain that have associations with reward, and these patterns of activation were different when playing with a group than when playing on the computer. Other new and exciting data are emerging to support the notion of experiential learning in groups as a viable means for increasing skills and awareness. Following is a sample of a simulation/game activity for a large group, of ten or more participants. The room should be large enough for small

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groups to work independently. The leader should select the topic for the creed in advance. Examples of a topic or focus for the creed include the following:






Spiritual, spiritual practices, or a spiritual person A positive work environment Hope, positive attitude Caring and compassion Tolerance, respect

An Example Creed AUTHENTICITY

I believe that authenticity is a valuable attribute that promotes deeper and more satisfying relationships Someone who is authentic can be trusted in what they say, and is congruent in their actions. You get and maintain authenticity when you have developed your self, have confidence that you are adequate and capable, and have reduced self-absorption. When you are not authentic, you can create ambiguity and uncertainty, promote distrust, and are demonstrating a lack of respect for your self and for others. Authenticity includes all aspects of life, valued relationships, and a commitment to oneself. We accept that becoming authentic is a process of developing oneself, is likely to be misunderstood and unrecognized by others, but is an essential component for initiating and maintaining enduring and satisfying relationships. Exercise 6.9 Creation of a Creed Goals or Purposes To demonstrate consensus building, and clarify beliefs about the topic. Materials Paper and pencils for writing, large sheets of paper for each subgroup to write their creed. Write a list of the tasks on a posted large sheet of paper or a whiteboard (tasks: formulate a written creed arrived at by consensus, draft a position statement about the creed, and select a representative to deliver the statement and creed) and the following outline of statements that are included in a creed on another large sheet of paper to be posted.

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Creed Outline I believe__________________ is Someone who is____________ You get and maintain ________ when you abide by the principles When you are not _____ you’re ________ includes these aspects of one’s life Procedure Explain that the task will be to develop a creed statement that presents their beliefs that they hold in common about the topic, which is a public affirmation of those beliefs, and which members can and do follow. 1

2

3 4

5

6

7

Divide the group into small groups of participants, and place the groups in different places in the room. Groups do not have to be equal in size, but that is the ideal. Distribute the materials, and tell them the topic for which they will provide a creed. All small groups should work on developing a creed for the same topic or concept, and a position statement, such as why this is important. Tell them the time frame for development, and that the representative will report the creed to the large group. Another requirement is that the creed be a consensus agreement, no voting is allowed. Ask the groups to write their creed on the large paper, which will be posted for all to see. Allow sufficient time for the groups to work. Walk around and observe the actions and the process. Tell groups when there are about five minutes remaining to complete the task. Have each group representative report the creed and the position statement to the large group. Allow questions to be asked about content, but do not engage in exploration at this time. After each group has reported, ask what it was like to participate in the activity; what thoughts, ideas, and feelings emerged as they contemplated their perspectives for the topic or concept; and thoughts and feelings about the process used. If time permits, lead a discussion about the impact of the creed(s), how they are similar or how they are different; if it is possible to live by the creed; and if group members have reservations or are they committed what was developed.

Summary The nine activities presented are a variety of verbal and nonverbal ones focused on movement, dance, physical exercise, drama, and role play. These

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activities can give group members opportunities to gain perspectives that may have been hidden or overlooked. Body movements can be very revealing of nonconscious and unconscious experiencing that is then brought to members’ awareness for better understanding and that can be further explored.

References Alexandridis, G., Antoniou, A., & Petmezas, D. (2007). Divergence of Opinion and Post-Acquisition Performance. Journal of Business Finance & Accounting, 34, 439–460. https://doi.org/10.1111/j.1468-5957.2007.02043.x. Alpert, P., Miller, S., Wallmann, H., Haney, R., Cross, C., Cherulia, T., Gilles, C., & Kodandapari, K. (2009). The effect of modified jazz dance on balance, cognition, and mood in older adults. Journal of the American Academy of Nurse Practitioners, 21(2), 108–115. Burn, H. (1987). The movement behavior of anorectics: The control issue. American Journal of Dance Therapy, 10, 54–76. Byom, T. (2010). A comparison of the effectiveness of three group treatments for weight loss. Dissertation Abstracts International: Section B: The Sciences and Engineering, 2070. Dunne, P. (2010). Narradrama with marginalized groups: Uncovering strengths, knowledges and possibilities. In E. Leveton (Ed.), Healing collective trauma using sociodrama and drama therapy (pp. 25–53). New York: Springer. Ersek, M., Turner, J., Cain, K., & Kemp, C. (2009). Results of a randomized controlled trial to examine the efficacy of a chronic pain self-management group for older adults. Pain, 138(1), 29–40. Goleman, D., & Gurin, J. (1993) (Eds.) Mind/Body medicine: How to use your mind for better health. Yonkers, NY: Consumer Reports. Hackney, M., & Earhart, G. (2010). Recommendations for implementing tango classes for persons with Parkinson disease. American Journal of Dance Therapy, 32(1), 41–52. Hardcastle, S., Taylor, A., Bailey, M., & Castle, R. (2008). A randomized controlled trial on the effectiveness of a primary health care based counseling intervention on physical activity, diet, and CHD risk. Patient Education and Counseling, 70(1), 31–39. Hazlett, S. (2010) Attunement, disruption and repair: The dance of self and other in emotionally focused couple therapy. In A. Gurman (Ed.), Clinical casebook of couple therapy (pp. 21–43). New York: Guilford. Horwitz, B., Kowalski, J., & Anderberg, A. (2010). Theatre for, by and with fibromyalgia patients—Evaluation of emotional expression using video interpretation. The Arts in Psychotherapy, 37(1), 13–19. Hugill, N., Fink, B., Neave, N., & Seydel, H. (2009). Men’s physical strength is associated with women’s perceptions of their dancing ability. Personality and Individual Differences, 47 (5), 527–530. Karnezi, H., & Tierney, K. (2009). A novel intervention to address fears in children with Asperger syndrome: A pilot study of the cognitive behavior drama (CBD) model. Behavior Changes, 26(4), 271–282. Kunik, M., Veazey, C., Cully, J., Souchek, J., Graham, D., Hopko, D., & Stanley, M. (2008). COPD education and cognitive behavioral group treatment for clinically significant symptoms of depression and anxiety in COPD patients: A randomized controlled trial. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 38(3), 385–396.

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Langdon, S., & Petracca, G. (2010). Tiny dancer: Body image and dancer identity in female modern dancers. Body Image, 7(4), 360–363. Lima, M., & Vieira, A. (2007). Ballroom dancing as therapy for the elderly in Brazil. American Journal of Dance Therapy, 29(2), 129–142. Meyer, K. (2010). Drama therapy with adolescents living with HIV: Story making drama and body mapping. In P. Jones (Ed.), Drama as therapy V2: Clinical work and research into practice (pp. 126–151). New York: Routledge. Moreno, J. L. (1964). Psychodrama. Vol. 1. Beacon, NY: Beacon. Morris, C., & Moore, E. (2009). An evaluation of group work as an intervention to reduce the impact of substance misuse for offender patients in a high security hospital. Journal of Forensic Psychiatric & Psychology, 20(4), 559–576. Oon, P. (2010). Playing with Gladys: A case study integrating drama therapy in behavioral interventions for the treatment of selective mutism. Clinical Child Psychology and Psychiatry, 15(2), 215–230. Park, C., & C. Blumberg (2002). Disclosing trauma through writing: Testing the meaning making hypothesis. Cognitive Therapy and Research, 26, 597–616. Payne, H. (2009). Pilot study to evaluate dance movement psychotherapy in patients with medically unexplained symptoms. Journal of Body, Movement and Dance in Psychotherapy, 4(2), 77–94. Periman, L., Cohen, J., Altiere, M., Brennan, J., Brown, S., Mainka, J., & Diroff, C. (2010). A multidimensional wellness group therapy program for veterans with comorbid psychiatric and medical conditions. Professional Psychology: Research and Practice, 41(2), 120–127. Sherman, K., Heard, G., & Cavanagh, K. (2010). Psychological effects and mediators of a group multi-component program for breast cancer survivors. Journal of Behavioral Medicine, 33(5), 378–391. Singer, T. & E. Fehr (2005). The neuroeconomics of mindreading and empathy. American Economic Review. 95(2), 340–345. Swami, V., & Tonee, M. (2009). A comparison of actual weight discrepancy, body appreciation and media influences between street dancers and non-dancers. Body Image, 6(4), 304–307. Veenstra, E. (2010). Improvisational theatre and psychotherapy: A new model. Dissertation Abstracts International Section B: The Sciences and Engineering, 7867. Xia, J., & Tessa, J. (2009). Dance therapy for people with schizophrenia. Schizophrenia Bulletin, 35(4), 675–676.

Chapter 7

Imagery, Mindfulness, and Music

Introduction Creative activities incorporating imagery, mindfulness, and music can tap other dimensions of experiencing for group members. People learn in different ways and these modalities can be used to enhance and expand learning and understanding of oneself and of others. Although each of these, when used as a focus and emphasis for therapy, call for specialized training, there are activities that can be adapted for use by group leaders who do not have that training. However, it is recommended that group leaders have some formal training with the technique or modality, such as taking a workshop, prior to using it with a group. Imagery is a process for visualization of thoughts, feelings, ideas, wishes, dreams, or fantasies that may be conscious or unconscious. These visualizations can increase awareness and understanding, suggest possibilities and alternatives, make conscious the nonconscious and unconscious material, and can provide comfort and solace. Mindfulness is a technique that has its roots in meditation, but has been expanded to provide focus and concentration in all aspects of one’s life. Be here in the present is its mantra. Further, mindfulness has considerable research as to its efficacy for stress reduction, positive therapy outcomes, assistance with medical conditions, and other uses. Music therapy has been used for some time, and there is research to support its efficacy. Although what is presented in this chapter does not focus on music therapy, it does provide some activities involving music that can be used in groups.

Imagery A search of databases for research on the use of imagery in therapy revealed that the majority of studies were on medical conditions such as spasticity (Bovend’Eerdt et al., 2009), spinal cord injury, breast cancer, (Cameron et al., 2007), stroke and brain injury (Niemeier, 2001). These and other such studies on medical conditions used prerecorded imagery activities, or a therapist DOI: 10.4324/9781003251989-7

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trained in imagery techniques. Serious conditions like PTSD, medical conditions, diagnosed anxiety disorders, and the like require specialized training in imagery for therapy, and this kind of training is beyond the scope of this book. What is presented here are the short and simple imagery activities that do not call for formal specialized training in the use of the technique although readers are encouraged to participate in one or more workshops or classes on the technique. Such preparation can facilitate the use of simple and uncomplicated imagery techniques, and is useful in addition to the education and training in group therapy previously accomplished. This chapter focuses on using imagery for the following therapeutic reasons:






Teaching relaxation – reduce stress and tension Coping with negative emotions Preparation for performances, such as tests Coping with difficult situations, distress, and the like Learning about one’s self-perception

Guidelines Focus on a single purpose for using imagery in the group. Group members may benefit in a variety of ways from the activity, but having more than one therapeutic purpose and/or goal makes it too complicated and less likely to accomplish any of the intended purposes. The purpose or goals should be clear, specific, and focused on one of the reasons given in the introduction. Introduce the activity by describing what will be done and what members are expected to do. Imagery activities can be described as a visualization where the leader provides verbal cues for what to do, what to attend to, and so on. Members supply their personal responses and associations, and are encouraged to just let these emerge and to not try to alter these. Permission is given to stop imaging at any time by opening their eyes, and/or to not participate in the activity. There should be no penalty for declining to participate. Group leaders may want to secure recorded activities, such as for progressive relaxation. Scripts are also available if the leader feels it important that group members hear them providing the instructions. Most of the activities presented in this book and in this chapter have a script the group leader can use. When reading or providing a script, be sure to do so with suitable pauses of sufficient time to allow members’ images to emerge. What can appear as a long time to the leader can be experienced as a very short time to the group members. Writing, drawing, or other expressive techniques are useful adjuncts for imagery. Writing or drawing their images allows group members to capture them before they become contaminated by thoughts, judgments or

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evaluations, or by hearing what others experienced. Some group members may not need to write or draw, but using these techniques with the imaging can still be helpful. For example, I find that members’ images of a place of peace seem to become more vivid and fixed when they draw after imaging. Imagery This chapter begins a little differently than other chapters by starting with an activity to help set the frame for using imagery. The technique of imagery comes from behavioral therapy, particularly that of the multimodal therapy by Lazarus (1989), and has many applications. Many of these will be presented and discussed later in the chapter. An activity is introduced now whose purpose is to provide group members with a refuge to retreat to when encountering distress or intense negative feelings. Imagery activities can trigger these for some people, and other theories and therapies, such as Dialectical Behavioral Therapy, Cognitive Therapy, and Eye Movement Desensitization Reprocessing (EMDR) present such a refuge prior to working with their serious issues and concerns. Although the activities in this chapter should not produce distress, the possibility does exist that some group members may experience this, and the following activity can be helpful. It is also a good way to introduce group members to imagery. Activity 7.1 A Haven Materials None if imagery alone is used, but if drawing the image is a part of the activity, the following materials will be needed: paper, a set of crayons or colored pencils or felt markers for each group member. 1

2

Introduce the activity by telling group members that they may want to have a respite from distress or intense negative feelings at times, and the image they produce from this activity will be there for them to visit at any time. Tell them that the process will be as follows. You will ask them to close their eyes, and let the designated image emerge without trying to change or evaluate it as good or bad, right or wrong. If the image is disturbing, opening their eyes brings them back to the room and stops the imaging. Determine if anyone wants to opt out of doing the activity and give them permission to do so. Ask members to close their eyes and to become aware of their breathing. Note if their breath is deep and even, short and jerky, or if they are having difficulty breathing, e.g. a medical condition. Give 5–10 seconds for this. Next, ask them to try and breathe deeply and evenly, and to notice how this makes them feel. Give another 5–10 seconds for this part.

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Provide the following directions. “As you sit in silence, and your breathing becomes deeper and more even, allow an image to emerge of a place that gives you feelings of safety, peace, and serenity. (Allow 5–10 seconds at least for an image to emerge). Begin to notice details about your place of haven. It a place where you can go at any time to be safe, peaceful, and serene. What do you see? What do you hear? What other sensations do you have? (Allow 15–20 seconds or longer to fix the image in their minds.) When you are ready, open your eyes and come back to the room”.

4

5

Ask each member to describe their image. Note similarities among members, but do not explore these or the images in detail. If you use drawing, ask members to first draw their images, and then present these to the group. Have group members explore the following questions: Was it easy or difficult to have an image emerge? What feelings were triggered for you as you imaged? Talked about your image? Was it difficult to try and make your breathing deep and even? Did this produce some calmness for you? How do you feel now about your image?

This activity was presented first because imagery can be frightening and/or distressful at times for some people, and having a safe haven image can be reassuring. This image provides group members with a means of support in the event of distress as they engage in other imagery activities, or in any of the other expressive activities described in the book.

Reducing Tension and Anxiety Marra (2005) describes anxiety as causing muscle tension and aches, reducing the effectiveness of your ability to concentrate and pay attention, interfering with decision-making, and lessening your capacity to experience joy, pleasure, and the like. Physical symptoms can be restlessness, irritability, fatigue, heart palpitations, breathing difficulties, and continual worry. Anxiety interferes with almost every aspect of one’s life. Teaching group members progressive relaxation could be helpful to counter tension and anxiety. The script for relaxation is long, and readers are encouraged to locate a professional tape to use. However, there are short relaxation activities that can produce enough relaxation for members to feel the difference, and that will help in producing images. One such activity follows.

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Activity 7.2 Body Tension Materials None Procedure 1

2

3

4

5

Introduce the activity by describing some of the effects of tension on the body and mind. Tell group members that you will guide them in a short activity that could reduce some of the tension. They can participate with their eyes closed or open. Closed eyes usually facilitate concentration on the body. Survey group members as to the level of tension they currently feel rating it 0 (no tension), to 10 (extremely tense). Also ask them where the major tension is in their bodies. Ask members to close their eyes and concentrate on their breathing, and note if it is jerky, short, coming from their chest, or however it is at this moment. Allow 15–20 seconds. Next, ask them to consciously try to deepen their breath and to breathe from their diaphragm (top of stomach). Tell them if they have difficulty to just keep concentrating on their breathing. Guide members through the following sequence. “We’re going to journey through your body from the top of your head to your toes. Along the way, become aware of any tension in that part of the body. You can consciously relax the tension by contracting or tightening the muscles, holding the contraction, and then release the contraction”.

1

2 3

4 5 6

7

We begin with the head. Notice if there is tension, tighten the muscles, hold it, and let go. (Provide at least 10 seconds between instructions to allow members to contract, hold, and let go.) Next, we move to the neck. Notice if there is tension. If so, gently move your head from one side to the other to tighten those muscles and let go. Notice if there is tension in your shoulders. If so, hunch your shoulders up toward your ears, hold it, and then let go. You can do this several times if needed. Move to your arms and hands. If there is tension, make a fist as tightly as you can, hold and release. This should help release tension in the arms and hands. Notice if there is tension in your chest. Breathe deeply and evenly to release this tension. Move to noticing if there is tension in your stomach. To contract these muscles, pull your stomach in as far as you can, hold it, and then let go. You can do this several times. Notice if there is tension in your legs. Try to contract those muscles, hold it, and then release.

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9

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We’ve reached the feet and toes. If you are able, flex your feet by stretching the leg horizontal, and flexing the toes to align with the heel. Feel the stretch, hold it, and then release. Perform a body scan by starting at the top of your head and progressing through the body. Notice where you have tension, tighten those muscles, hold it, and then release the contraction.

Coping With Negative Emotions Negative emotions such as anger, fear, and the like, also have negative effects on the body and mind. These can be triggered and become difficult to relinquish, or are so intrusive that the person cannot effectively function, or can be expressed in inappropriate ways so that relationships are impaired, and some group members may not know how to manage and contain these emotions to reduce these negative effects. While it can be best that members learn to work through these emotions, or gain insight as to their causes, what can be helpful in the short term is to give them a coping skill that can be used immediately when they experience these emotions. The following set of activities can help members develop distracting strategies as a coping skill that can be used when the negative emotions arise and linger. It is recommended that group leaders use the entire set of imaging activities since members will be responsive to differing distractions. Complete each activity before moving to the next one. Activity 7.3 Cope by Distracting Yourself Materials None Procedure Introduce the activity by telling group members that it can be difficult sometimes to cope with negative emotions, and that they can become enmeshed or overwhelmed, find it difficult to relinquish the particular emotion, and that becoming mired can affect them and others who have to interact with them. What is presented is a set of four imaging of distracting activities, and they will be taken through the entire set so they can better select the distracting image that best fits them. Activity 7.4 Visual Distraction Procedure 1

Ask members to sit in silence and to concentrate on their breathing for a few seconds. Then, ask them to allow a pleasant image to emerge, a visual

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2 3

experience, e.g. kittens romping, children at play, the beach, or anything that produces a feeling of pleasure. Tell them to note details of the image and surroundings. Tell members that when they are ready, to open their eyes and return to the room. Ask each member to share their image. After which, tell them that they can return to this image when they are distressed, or feel an intense negative emotion.

Activity 7.5 An Auditory Distraction Procedure 1

2 3

Ask members to sit in silence and concentrate on their breathing for a few seconds. Then, ask them to image a pleasant sound; a voice, music, birds singing, or whatever sound pleases them when they hear it. Tell members that when they are ready to open their eyes, and then to share their images. Tell them that the sound image can be used when distressed, or as a distraction from a negative emotion.

Activity 7.6 A Taste Distraction Procedure 1

2 3

Ask members to sit in silence and concentrate on their breathing for a few seconds. Then, ask them to image a pleasant taste, to become mindful of what it feels like on the tongue or in the mouth, the texture of the substance, and the feeling that it produces. Tell members that when they are ready, to open their eyes and then share their images. After step 2 is completed, tell them that they can return to this image as a distraction whenever they are distressed, or use it as a distraction from experiencing negative emotions.

Activity 7.7 Positive Touch Sensation Procedure 1

Ask members to sit in silence and concentrate on their breathing for a few seconds. Then, ask them to image a positive touch sensation where they feel something on their skin. This could be something like a spray of refreshing water, a silk garment, rubbing on lotion, and the like. (It’s probably best to

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not use an image or example of human touches since that can be upsetting to some group members who may have had negative experiences.) Tell members that when they are ready, to open their eyes and share their images. After step 2 is completed, tell them that they can return to this image to use as a coping strategy.

Imagery for Performances Performances such as taking a test, speaking in public, asking for a raise, and other such situations can be very anxiety provoking, and even paralytic for some people. The fear can be so pervasive that the person cannot access the energy, information, or other resources needed to carry through with the task. While one activity alone will not conquer this anxiety, an activity such as the following can show them that it is possible to reduce the anxiety and/or fear so that they can better perform whatever the task is. Activity 7.8 A Future Situation Materials A suitable surface for writing, sheets of paper, a pen or pencil. Procedure 1

2

3

4

5

Distribute materials and introduce the activity. Tell members that the activity you will guide them through is a preparation for a future situation. They are free to choose the situation. Examples could be taking a test, giving a talk in public, or any situation that produces considerable anxiety for them. Ask members to write a brief summary of the future situation. Give some time for them to finish, and ask if anyone wants to share their future situation. Next, have them list the steps they will take to approach the situation beginning with waking that morning, and to be as specific as possible about what those steps are. After the lists are complete, ask them to review their lists and to write what feeling they think is associated with the step. For example, getting out of bed may have dread associated with it because of anticipation of the future event. Next, ask them to write a statement or paragraph about what they could change that would allow them to behave differently. The change should be personal, not the situation or another person.

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6

Have members put the writing instrument down, sit in silence, close their eyes, and concentrate on their breathing. Use the following script to guide the imaging. “As you sit in silence, allow the future situation to emerge with the change in yourself that will permit you to behave differently in the situation. As the situation emerges, become aware of your feelings, your actions, and how you imagine the situation will unfold. Stay with the action as long as you can, noting as many details as you can. When your imaging has stopped, open your eyes and come back to the room”.

7 8

Allow enough time for the images to unfold. When all members have opened their eyes, ask them to briefly write about the imaging. Once that writing is complete, have members who wish to share the experience do so. Members should be free to not share if they choose.

Coping With Difficult Situations or Distress Some people find it difficult to cope with difficult situations or distress because they tend to “catch” others’ feelings. Their psychological boundary strength is insufficient to prevent others’ projections from being incorporated into their selves, accepted, and acted on. This is why they end up overly disturbed with intense emotions that do not disperse easily, they have their own feelings which are generally negative, and have now incorporated others’ negative feelings on top of what they were already feeling. These are also the people who generally find it difficult to say no to others, or to not give in to others’ demands. Psychological boundary strength refers to having a clear understanding of where and how you are a separate individual person from others, that is where you end and where others begin. The separation and individuation process described by Mahler (1975) is incomplete and the boundary strength is insufficient to keep others from projecting their negative emotions onto you. Growing in separation and individuation is a lifelong process, and when there are developmental delays, the person can have weak psychological boundaries. Growing strong and resilient psychological boundary strength takes time and effort and is beyond the scope of this book to explain and describe. What is presented here is a short activity that group members could use while they are working on developing and fortifying their psychological boundary strength. The imaging activity gives them some emotional insulation that can be employed to prevent taking in other’s negative feelings, criticisms or blame. (Brown, 2009) Activity 7.9 Boundary Fortification Materials Paper or large index cards, a set of crayons or colored pencils or felt markers for each group member.

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Procedure 1

2 3

Introduce the activity by telling members that there are times when you feel disturbed or distressed in interactions with other people because you cannot prevent their feelings from overwhelming you, or you become enmeshed in their feelings. You “catch” their feelings. You may even have termed this as being “too empathic”, but what may be happening is that your psychological boundary strength is not sufficient to prevent this from happening. (The leader should be prepared to describe what catching means, and to give examples such as what is presented in the introduction to this activity.) Explain that this activity will give them a short-term strategy to help prevent “catching others’ feelings”. Ask members to sit in silence and concentrate on their breathing and to try and make it deep and even. As they sit in silence, use the following script. “Image a barrier between you and another person that will allow you to hear what they are saying, but will prevent you from catching their projected feelings. This barrier can be something like a door you close, a shade you pull down, a sliding steel wall that you close, a force field. It can be anything you choose, just image what barrier you could use to prevent you from becoming distressed, overwhelmed or enmeshed in their feelings. Stay with the image and notice all the details you can. When you are ready, open your eyes, come back to the room, and draw your barrier”.

4 5

After the drawing is complete, ask members to share their drawings and note similarities between choices of barriers. Tell members that they can image the barrier at any time, before they interact with someone that seems to always leave them disturbed, and/or when they are in an interaction and find that they are becoming distressed or disturbed.

Self-Perception This section will present an activity to take inventory of members’ selfperception in a way that can reveal their degree of satisfaction with different aspects of the self by comparing the current perception with the ideal they hold for themselves. Because humans are multifaceted, it is not unusual to find that some aspects of self are perceived positively, others may be perceived negatively, but almost everyone has some part of their self that they want to improve or change. The expansion and enhancement phase of the activity can guide members in developing action plans for the desired changes.

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Activity 7.10 Self-Perceptions Materials Two sheets of paper with the columns labeled as designated below for each member (the space for each column can be larger); a set of crayons, colored pencils, or felt markers for each group member. CURRENT

Physical

Cognitive

Emotional

Creative

Relational

Spiritual

Cognitive

Emotional

Creative

Relational

Spiritual

IDEAL

Physical

1

2

After distributing the materials, ask group members to sit back and close their eyes. Tell them you will present each aspect separately giving enough time for the image to emerge, and then ask them to open their eyes and draw. You will ask them to image six times, and to draw six times. Present each aspect separately asking them to image that part of their current selves. Allow 30–40 seconds for the image to emerge. After each one, ask them to open their eyes and to draw the image that emerged. Physical Cognitive Emotional Creative Relational Spiritual

3

4 5

After all six drawings are complete, ask group members to share their drawings. You can approach this by doing all drawings for one aspect at a time, or have members present all six aspects of their self at one time. Repeat steps 1–3, substituting ideal self. Questions to guide self-exploration follow.

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How are the symbols for the different aspects of your current and ideal self alike? Different? Which aspect(s) of your current self is (are) most pleasing to you? Are there any aspects that are displeasing to you? Are there any aspects of your ideal self that are unrealistic to obtain, achieve, etc.? Which are achievable? Do you have an action plan to achieve the ideal aspect(s)?

Addressing Group Concerns When the group encounters a dilemma, or when members are suppressing feelings or conflict, it can be helpful to do an imagery activity that focuses on the group as a whole. Such an activity can provide a way for group members to express difficult thoughts and feelings, to clarify what they sense is happening in the group, can be a safe way to express what they fear to openly say, and can allow the group leader to bring a difficult situation to the attention of the group. The following activity could address unspoken group concerns. Activity 7.11 Image of the Group Materials None unless the leader wants to have the group write or draw the image. Procedure 1

2

3 4

5

Ask members to sit in silence, concentrate on their breathing to try and relax, and to close their eyes. Tell them you are going to ask them to allow an image to emerge. Begin by telling members how many sessions the group has met, and that they have discussed many topics during that time. Ask them to reflect on their experiences in the group, and to allow an image of the group to emerge. The image can be symbolic, abstract, or whatever comes up for them. Allow enough time for the imaging. Tell them that when the imaging stops, to open their eyes and come back to the room. Have a go around to let members share their images. Or, if they draw or write, provide enough time for this and then have them share their images. Observe similarities, differences, and ask members what their associations are for the images, either their own, or that of others.

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6

Try to summarize what the images are presenting about the group as a whole in the present and invite members to provide their input about your summary.

Mindfulness and Music: Mindfulness Mindfulness occurs when you can stay focused on your thoughts, feelings, physical sensations and actions in the present moment. In some ways, it is akin to meditation, but is more extending than meditation as it seeks to expand your awareness to both the inner and external experiencing. This section presents an overview of some literature demonstrating the effectiveness of mindfulness, the benefits for using it as a group activity, and some examples. Kabat-Zinn is credited with conducting the research on use of mindfulness with patients with chronic pain (Kabat-Zinn et al., 1985). This pioneering research demonstrated a significant reduction (33%) in the pain rating index after ten weeks of participation in mindfulness lessons, and also reductions in mood disturbances and symptomatology. Subsequent studies by Goleman (2003), Kabat-Zinn et al. (1992, 1998), Segal et al. (2002), Teasdale et al. (2000) provided additional evidence of mindfulness’s efficacy for pain reduction. Mindfulness has been shown to be effective in several studies about diverse illnesses and conditions. Evans et al. (2007) used a mindfulness-based intervention with patients with anxiety disorders and found that symptoms of anxiety and depression were reduced. Kingston et al. (2007) used mindfulness with patients experiencing continuing symptoms after a depressive episode. They found that the depressive symptoms and rumination decreased, and this continued when measured a month later. Barnes et al. (2007) studies on mindfulness and relationships linked mindfulness with positive relationships. Carlson and Garland (2005) studied the use of mindfulness with cancer patients who had sleep disturbance. The results showed a decrease in sleep disturbances and an increase in sleep quality. Prouix (2008) used mindfulness in the treatment of bulimia and found that subjects showed improvement in emotions, behavior, self-awareness, and acceptance. Other research examples include the following.







The elderly (Alexander et al., 1989) Gaining therapeutic insight (Kutz et al., 1985) Cancer (Carlson et al., 2003; Speca et al., 2000) Sleep disorders (Shapiro et al., 2003) Positive effects on quality of life (Reibel et al., 2001) Stress reduction (Davidson et al., 2003)

Mindfulness is also effective with children and adolescents. Saltzman (2008) used mindfulness training for eight consecutive weeks with a sample of fourth to seventh grade children and their parents. Outcomes included an increase in

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the ability to pay attention, and a decrease in anxiety. Biegel (2009) found that adolescents who had been diagnosed as depressed and anxious were able to experience reduced symptoms related to anxiety and depression, and increased self-esteem and quality of sleep. An important use for mindfulness is seen in the incorporation of it as an integral part of Dialectical Behavioral Treatment (DBT). It is used to increase selfacceptance, becoming non-judgmental about self and others, learning emotional regulation, and other therapeutic tasks in this system. Although the treatment system was initially developed to treat parasuicidal patients, it has been expanded as treatment for Borderline Personality Disorder, mood, anxiety, addictive, eating, impulse-control, and other personality disorders (Marra, 2005). The proposed uses in this book are for both the group leader and for group members. The group leader can increase their emotional presence and observational skills in the group. Members can benefit from learning how to expand their internal and external experiencing; quiet, calm, and focus their thoughts and feelings; and gain more self-acceptance. Two principles from Tao that can be useful in mindfulness are the Principle of P’u, and the Principle of Wu Wei. The Principle of P’u is described as the state of the uncarved block which Hoff (1983) terms as the ability to attend to the simple and the quiet, the natural and the plain. This state promotes experiencing things and people without making judgments or evaluations. The Principle of Wu Wei refers to do by not doing, allowing experiences to unfold and happen without trying to influence or change them. When applied to mindfulness, the two principles mean to attend to what is your internal and external experiencing without making judgments or evaluations; and to be content to allow your experiencing to unfold without trying to direct them in a particular pathway. These will be the major directions for the mindfulness activities that are included. It is recommended that the group leader practice mindfulness activities before introducing them to the group. The first activity is also a script that can be used when presenting mindfulness to group members. It is helpful for the group leader to practice the activity for at least 15 minutes a day for 21 days so that it becomes effortless, and the leader has a richness of experiences to guide them. Activity 7.12 Mindfulness Activity Materials A notebook or paper and pen to record your experiences. Procedure 1 2

Make a commitment to practice mindfulness a minimum of 15 minutes every day for a specified period of time, for example 21 days. Read the following script, and then follow it.

152 Imagery, Mindfulness, and Music MINDFULNESS SCRIPT

Find a place to practice where you will not be disturbed. Begin by sitting in a comfortable position. You can do the activity with your eyes open, or closed whichever is most comfortable for you.









Focus on your breathing, and try to make it even and deep. Become aware of your body and notice any physical sensations you are experiencing. Scan your body from the top of your head to your feet and note muscle tension, relaxed parts, tingles, etc. Notice any smells you experience; pleasant, unpleasant. If you don’t notice any, concentrate on your breath and how the air feels as you take it in, and let it out. Redirect your focus to your sense of hearing. Notice what sound you hear; near, far, loud, and/or quiet. If your thoughts emerge, just redirect these to the sounds. Attend once again to your breathing, and notice if there are any changes. Let yourself become aware of what you are feeling at the moment, and note if there are changes. Try to sit in silence for the entire 15 minutes and just allow your feelings, thoughts, and ideas to emerge without following them, emphasizing them, or evaluating them. It can be helpful to write a brief summary of your experience each day.

It is not unusual for people to find it difficult to keep their thoughts from becoming central when they try to practice mindfulness. After all, there are usually tasks that have to be accomplished, planning and organizing for future tasks, concerns and worries, and so on that can be difficult to shut down and enter a state of mindfulness. It is helpful to be able to empty the mind, but that is difficult to do at times, especially when beginning the practice. However, if you persist, you will find this useful in all kinds of situations, such as trying to fall asleep at night. One way of keeping your thoughts and feelings from intruding, or taking over is to use the thought defusion strategy described by Hayes, Strosahl, and Wilson (1999). The following activity demonstrates the strategy. Activity 7.13 Passing Thoughts Materials None

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Procedure Find a place to work that is free from distractions and where you will not be disturbed. 1 2

Sit in silence with your eyes closed, and allow your breathing to become deep and even. As you sit in silence, thoughts and feelings may arise. Picture each thought and/or feeling as one of the following: a b c d e

3

4

A bird flying by A billboard sign you see as you ride by on a bicycle On water swirling down a drain Pollen, blown by the wind out of sight Any image where the thought or feeling is noticed but then, disappears

If you find that you are staying with a thought or feeling, return to your breathing, and try again to notice the thought or feeling as it is passing by you, but not lingering. The next activity is using mindfulness to cope with a distressing or negative feeling.

Activity 7.14 Managing Emotions Materials None Procedure 1 2 3

4 5

Find a place to practice where you will not be disturbed, and that is free from distractions. You can either close your eyes or let them stay open. Identify your current dominant feeling, such as anger, sadness, and the like. Refrain from making a judgment about the feeling, such as it being good or bad, right or wrong. Perform a body scan and identify all sensations you are experiencing for example: breathing hard, your heart racing, muscle tenseness, and so on. Next, concentrate on one sensation at a time, and try to control your breathing. If muscles are tense, tighten these, hold and then let go. Identify where the feeling is located in your body and focus on each of the following characteristics.




What shape does the feeling have? What is the weight? Heavy? Light? Moderate? What is its color?

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6

Is the feeling moving; such as pulsating, moving from place to place, etc., or does it remain in one place?

Once you have completed the first set of questions in step 5, repeat it three times, and then note if there are any changes in the location, shape, weight, color, or movement. It may be that the feeling has been reduced, subsided, or in some cases, it no longer exists.

Music Music therapy requires the leader to have specialized training. What is presented here are a few simple activities that use music as a stimulus to energize, calm, and/or to evoke emotions, but not as healing or for deep exploration of personal issues. Babani (2010) in a qualitative study on musical-triggered peak experiences notes that “many individuals find that music activates insight, inspiration, emotional catharsis, and enhanced self-awareness”. Hays (2005) in a study on older adults found that meaning from the music experience was related to personal identity, self-expression, and feelings of wellbeing. Thus, music can activate many aspects of the self to promote understanding and increase awareness of experiencing. Hodas (1994) proposes that music can influence the course of therapy by increasing morale, providing validation and change for belief systems, and promoting the therapeutic relationship. It is a way to tell a personal story, and deepen connections. (Duffey et al., 2005; Hays & Minichiello, 2005). Silverman (2010) obtained the perceptions about five different modalities for music therapy from psychiatric inpatients who were severely and persistently mentally ill. Participants reported the individual music game as the most helpful, and the group musical game as the most enjoyable. The effects of music seem to be positive on a range of physical, neurophysiological, and psychological conditions. Trained clinicians use music therapy with a variety of medical illnesses and conditions such as the following:






Cancer (Boldt, 1996; Sabo & Michael, 1996; Williams et al., 2010) Organ transplant patients (Madson & Silverman, 2010) Premature infants’ treatment (Gooding, 2010) Parkinson disease (Batson, 2010) Cognitive rehabilitation (Thant, 2010)

Research on treatment of emotional disturbances with music therapy has also shown to be effective. Examples of such studies include:



Stress and anxiety (Hunter et al., 2010) Depression (Brandes et al., 2010; Castillo-Perez et al., 2010; Compass et al., 1998)

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Aggressive and oppositional children (Foulkrod & Davenport, 2010) Bereaved teenagers (McFerran et al., 2010)

Burns (2001) describes studies that integrate music and imagery with the outcome of making the image “more vivid” (McKinney, 1990; McKinney & Tims, 1995). A study by Band (1996) showed that the combination of music and imagery led participants to become more immersed in the image, and Quittner and Glueckauf (1983) proposed that music facilitated the emergence of images. The review of literature also shows that music is combined with movement (Luck et al., 2010); dramatherapy (Chipman, 2010); dance (Wengrower, 2010); art therapy (Crawford et al., 2010), and recreation therapy (Bauer, 2010). Since music can and does evoke emotions, images, memories, and the like, the group leader should have an understanding of the importance of selection of the pieces of music to be used in the group. In addition, it is also helpful to have a pretty comprehensive knowledge of all types and kinds of music such as classical, jazz, gospel, country, hip-hop, rap, rock, tech rock, pop, and rhythm and blues to name a few. Trained music therapists will also know of specific selections and performances within types and kinds of music and be able to connect the renditions with the needs of the group members and the goal(s) for using music in the group. It’s very complex to try and match music to the group’s needs, and to decide what mode of presentation, such as listening or singing, to be used. While art talent is not essential to the use of techniques such as drawing or collage, it is difficult to see how music can be effectively used without some musical talent, knowledge, and training. The group leader may want to consult with a trained music therapist about how best to incorporate music into the group session, and on the selection of music. Following are some short musical activities that can be used by almost any group leader. Activity 7.15 Music and Feelings Materials A boom box or other device for playing prerecorded music; three musical selections to evoke energy, reminiscence, and calmness. Procedure 1

2

Introduce the activity by telling group members that you will play three musical selections, and after each, they are invited to report on the feelings evoked by the selection. Play selection one for about five minutes, stop, and ask group members to report on their feelings.

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3 4 5

Play selection two for about five minutes and repeat the process described in step 2. Play selection three for about five minutes and repeat step 2. Lead a discussion on the evoked feelings, and the feelings they are experiencing now.

Activity 7.16 What Am I Thinking and Feeling? Materials A boom box or other device for playing prerecorded music; a musical selection that will be good as a background, paper and a set of crayons, colored pencils, or felt markers for each group member. Procedure 1

2

3 4 5

Introduce the activity by telling group members that you will play a musical selection, and they are to draw whatever they want as they listen. Tell them to try and just let the drawing emerge. They can begin drawing whenever they like, but you will be playing the selection for about five minutes. Start the music, and observe what group members do. Do some begin with the music or shortly thereafter? Do some listen for a period of time and then begin drawing? What do you observe about their nonverbal behavior? Stop the music and reconvene the group in the circle. Have members display their drawings, and describe their experience of listening and drawing. Ask them to explore how the music and drawing reflected their thoughts and feelings in the moment, and if there are any surprises in their products.

Summary The chapter activities presented descriptions for sixteen activities that can be helpful to group members to increase their awareness, focus their thoughts and energy and to relieve tension and anxiety. These 16 nonverbal activities using mindfulness, imagery, and music are particularly helpful to bypass defenses so that some nonconscious personal material for group members can be more readily accessed and explored.

References Alexander, C., Langer, E., Newman, R., Chandler, H., & Davis, J. (1989). Transcendental meditation, mindfulness, and longevity: An experimental study with the elderly. Journal of Personality and Social Psychology, 57(6), 950–964.

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Babani, A. (2010). Exploring peak experiences as elicited by music: A qualitative study. Dissertation Abstracts International B., The Sciences and Engineering. 5804. Band, J. (1996). The influence of selected music and structured vs. unstructured inductions on mental imagery (Unpublished doctoral dissertation). University of South Carolina, Columbia. Barnes, S., Brown, K., Krusmark, E., Campbell, W., & Rogge, R. (2007). The role of mindfulness in romantic relationship satisfactions and responses to relationship stress. Journal of Marital and Family Therapy. Batson, G. (2010). Feasibility of an intensive trial of modern dance for adults with Parkinson disease. Complementary Health Practice Review, 15(2), 65–83. Bauer, C., Victorson, D., Rosenbloom, S., Barocas, J., & Silver, R. (2010). Alleviating distress during antepartum hospitalization: A randomized controlled trial of music and recreation therapy. Journal of Women’s Health, 19(3), 523–530. Biegel, G. (2009). Mindfulness-based stress reduction for the treatment of adolescent psychiatric outpatients: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 77(5), 855–866. Boldt, S. (1996). The effects of music therapy on motivation, psychological well-being, physical comfort, and exercise endurance of bone marrow transplant patients. Journal of Music Therapy, 33, 164–188. Bovend’Eerdt, T., Dawes, H., Sackley, C., Izadi, H., & Wade, D. (2009). Mental techniques during manual stretching in spasticity—A pilot randomized controlled trial. Clinical Rehabilitation, 23(2), 137–145. Brandes, V., Terris, D., Fischer, C., Loerbroks, A., Jarczok, M., Marc, N., et al. (2001). Receptive music therapy for the treatment of depression: A proof-of-concept study and prospectus controlled clinical trial of efficacy. Psychotherapy & Psychosomatics, 79(5), 321–322. Brown, N. (2009). Becoming a group leader. Upper Saddle River, NJ: Pearson Education. Burns, D. (2001). The effect of the Bonny method of guided imagery and music on the mood and life quality of cancer patients. Journal of Music Therapy, 38, 51–65. Cameron, L., Booth, R., Schlatter, M., Ziginskas, D., & Harman, J. (2007). Changes in emotion regulation and psychological adjustment following use of a group psy- social support program for women recently diagnosed with breast cancer. Psycho-oncology, 16(3), 171–180. Carlson, L., & Garland, S. (2005). Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress, and fatigue symptoms in cancer outpatients. International Journal of Behavioral Medicine, 12(4), 278–285. Carlson, L., Speca, M., Patel, K., & Goodey, E. (2003). Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic Medicine, 65(4), 571–581. Castillo-Perez, S., Gomez-Perez, V., Caliullo, M., Perez-Campos, E., & Mayoral, M. (2010). Effects of music therapy on depression compared with psychotherapy. The Arts in Psychotherapy, 37(5), 387–390. Chipman, L. (2010). Expanding the frame: Self-portrait photography in dramatherapy with a young adult living with cancer. In P. Jones (Ed.), Drama as therapy. New York: Routledge. Compass, B., Haaga, D., Keefe, F., Leitenberg, H., & Williams, D. (1998). Sampling of empirically supported psychological treatments from health psychology: Smoking, chronic pain, cancer, and bulimia nervosa. Journal of Consulting and Clinical Psychology, 66, 89–112.

158 Imagery, Mindfulness, and Music Crawford, M., Killaspy, H., Kalaitzaki, E., Barrett, B., Byford, S., Patterson, S., Waller, D. (2010). The MATISSE study: A randomized trial of group art therapy for people with schizophrenia. BMC Psychiatry, 10, Article 65. Davidson, R., Scherer, K., & Goldsmith H. (Eds.). (2003). Handbook of affective sciences. New York: Oxford University Press. Duffey, T., Somody, C., & Clifford, S. (2005). Conversations with my father: Adapting a musical chronology and the emerging life song with older adults. Journal of Creativity in Mental Health, 2(4), 45–63. Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2007). Mindfulness based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22(4). 716–721. http://doi.org/10/1016/j.janx.2007.07.05. Foulkrod, K., & Davenport, B. (2010). An examination of empirically informed practice within case reports of play therapy with aggressive and oppositional children. International Journal of Play Therapy, 19(3), 144–158. Goleman, D. (2003). Destructive emotions: How can we overcome them? A scientific dialogue with the Dalai Lama. New York: Bantam. Gooding, L. (2010). Using music therapy protocols in the treatment of premature infants: An introduction to current practices. The Arts in Psychotherapy, 37(3), 211–214. Hayes, S., Strosahl, K., & Wilson, K. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford Press. Hays, T. (2005). Well-being in later life through music. Australasian Journal of Aging, 24, 28–32. Hays, T., & Minichiello, V. (2005). The meaning of music in the lives of older people: A qualitative study. Psychology of Music, 33, 437–551. Hodas, G. (1994). Reversing narratives of failure through music and verse in therapy. The Family Journal: Counseling and Therapy for Couples and Families, 2, 199–207. Hoff, B. (1982). The Tao of Pooh. New York: Penguin Books. Hunter, B., Bryan, C., Oliva, R., Sahler, O., Gaisser, E., Salipanto, D., & Arezina, C. (2010). Music therapy as an adjunctive treatment in the management of stress for patients being weaned from mechanical ventilation. Journal of Music Therapy, 47(3), 198–219. Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8(2), 163–190. Kabat-Zinn, J., Massion, A., Kristeller, J.Peterson, L., Fletcher, K., Lenderking, W. (1992). Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. American Journal of Psychiatry, 149, 936–943. Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, A., Scharf, M., Cropley, T. (1998). Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA). Psychosomatic Medicine, 60(5), 625–632. Kingston, T., Dooley, B., Bates, A., Lawlor, E., & Malone, K. (2007). Mindfulness based cognitive therapy for residual depressive symptoms. Psychology and Psychotherapy. Kutz, I., Borysenko, J., & Benson, H. (1985). Meditation and psychotherapy: A rationale for the integration of dynamic psychotherapy, the relaxation response, and mindfulness meditation. American Journal of Psychiatry, 142(1), 1–8. Lazarus, A. (1989). The practice of multimodal therapy. Baltimore, MD: John Hopkins University Press.

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Luck, G., Saarikallio, S., Burger, B., Thompson, M., & Toiviainen, P. (2010). Effects of the Big Five and musical genre on music-induced movement. Journal of Research in Personality, 44(6), 714–720. doi:10.1016/j.jrp.2010.10.001. Madson, A., & Silverman, M. (2010). The effect of music therapy on relaxation, anxiety, pain perception & nausea in adult solid organ transplant patients. Journal of Music Therapy, 47, 220–232. Mahler, M. (1975). On the current status of the infantile neurosis. Journal of the American Psychoanalytic Association, 23(2), 327–333. Marra, T. (2005). Dialectical behavioral therapy in private practice. Oakland, CA: New Harbinger. McFerran, K., Melina, R., & O’Grady, L. (2010). Music therapy with bereaved teenagers: A mixed method perspective. Death Studies, 34(6), 541–565. McKinney, C. (1990). The effect of music on imagery. Journal of Music Therapy, 27, 34–46. McKinney, C., & Tims, F. (1995). Differential effects of selected classical music on the imagery of high versus low imagers: Two studies. Journal of Music Therapy, 32, 22–45. Niemeier, J., Cifu, D., & Kishore, T. (2001). The lighthouse strategy: Improving the functional status of patients with unilateral neglect after stroke and brain injury using a visual imagery intervention. Topics in Stroke Rehabilitation, 8(2), 10–18. Prouix, K. (2008). Experiences of women with bulimia nervosa in a mindfulness based eating disorder treatment group. Eating Disorders, 16(1), 52–72. Quittner, A., & Glueckauf, R. (1983). The facilitative effects of music on visual imagery. Journal of Mental Imagery, 105–120. Reibel D. K., Greeson J.M., Brainard G. C., Rosenzweig S. (2001). Mindfulness-based stress reduction and health-related quality of life in a heterogeneous patient population. Gen Hosp Psychiatry. Jul-Aug23(4), 183–192. doi:10.1016/s0163-8343(01) 00149-9. PMID: 11543844. Sabo, C., & Michael, S. (1996). The influence of personal message with music on anxiety reduction with university students. Cancer Nursing, 19, 283–289. Saltzman, A. (2008). Mindfulness-based stress reduction for school age children. In Acceptance and mindfulness treatments for children and adolescents: A practitioner’s guide. Oakland, CA: New Harbinger. Segal, Z., Williams, J., & Teasdale, J. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford. Shapiro, S., Bootzin, R., Figueredo, A., Lopez, A., & Schwarta, G. (2003). The efficacy of mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: An exploratory study. Journal of Psychosomatic Research, 54(1), 85–91. Silverman, M. (2010). Applying levels of evidence to the psychiatric literature base. The Arts in Psychotherapy, 37(1), 1–7. Speca, M., Carlson, L., Goodey, E., & Angen, M. (2000). A randomized, wait-list controlled clinical trial: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine, 62(5), 613–622. Teasdale, J., Segal, Z., Williams, J., Ridgeway, V., Soulsby, J., & Lau, M. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615–623. Thant, M., & Abiru, M. (2010). Rhythmic auditory stimulation in rehabilitation of movement disorders: A review of current research. Music Perception, 27(4), 263–269.

160 Imagery, Mindfulness, and Music Wengrower, H. (2010). The dance of discovery: Research and innovation in dance/ movement therapy. Body, Movement and Dance in Psychotherapy, 5(2), 203–205. Williams, P., Balabagno, A., Manahan, L., Piamjariyakul, U., Ranallo, L., Laurente, C, Williams, A. (2010). Symptom monitoring and self-care practices among Filipino cancer patients. Cancer Nursing, 33(1), 37–46.

Chapter 8

Stories, Memories, Photos, Visual Journals, Flats, and Books

Introduction This chapter begins with a discussion and activities around stories that can be characterized as folk tales, legends, fables, myths, and fairy tales. Although these stories are usually thought of as ways to entertain and, in therapy, to have therapeutic outcomes for children, this presentation emphasizes their benefits for adults. Another presentation focuses on memories and how these can be worked on if they are sad or expressed and intensified if they are happy ones. Flats form the basis for another presentation.

Stories and the Unconscious A primary benefit for using stories in therapy is that they can help make the unconscious and nonconscious visible and conscious. Many people have little awareness of the impact of these invisible forces on their conscious and functioning and while stories are generally used with children, it can be very helpful for the adult group members to assist them in better understanding their selves. These can build greater awareness of the forces that influence their actions, thoughts, and ideas. Bettelheim (1976) writes, “In the child or adult, the unconscious is a powerful determinant of behavior” (p. 7) and as such, is a rich source of information about anxieties, fantasies, fears, hopes, and wishes as well as material for creative and inspirational pursuits. It is through this material that some of the psychological growth concerns are addressed: adjusting to narcissistic disappointments, resolving sibling and/or parental rivalries, becoming independent and separate, and developing healthy self-esteem. But, when the unconscious material is either kept rigidly under control or emerges in the conscious as overwhelming derivations of the constructs, rather than being integrated, the person cannot make constructive use of the material. When keeping threatening material suppressed or repressed as a defense it can lead to the hampering of expected development and produce impaired or ineffective functioning. This is the pattern from childhood on; DOI: 10.4324/9781003251989-8

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the adult can become severely hampered in functioning by keeping the feared material from the conscious. The fearful, threatening, and potentially shameful nature of the unconscious material in the unconscious can lead to the use of defenses; both to keep from knowing and to prevent others from seeing. Adults in therapy have had numerous years of employing their defenses, and are afraid to let go of these as they fear the material that will be revealed to self, and/or to others will be extremely shaming. This is only one reason why therapy is an uncovering process that helps peel away layers to correct misperceptions, integrate polarities, rediscover parts of self, reclaim disowned parts of self, and to develop a more cohesive, grounded, and centered self. These defenses are generally strong, of long standing, and effective so that it is difficult for the person to relinquish them. This may be especially so in groups where there are strangers who would see the shame. Group leaders must be understanding, tolerant, and patient and not expect group members to lower their defenses any time soon. However, through the use of stories they can be encouraged and become hopeful that they too can work through their problems. They realize that they are not alone in these struggles, and that their inner conflicts are not unique to them, but are an expected part of growth and development, and that moral development leads to greater belonging and connections. Feeling encouraged and hopeful, they can be less discouraged when things don’t work out as planned, or when their attempts at solving problems are not entirely successful, or when other concerns emerge. They now have more confidence in their ability to cope and manage their emotions, and to seek guidance from within themselves. They can become more independent.

Forms for Stories The forms for stories in this presentation are limited to folk tales, legends, myths, fables, and fairy tales. Fairy tales are the stories used for the discussion and focus for the creative activities. Folk tales tend to be universal because, although the characters have different names, and some details vary, the essential story remains the same in many countries. Many folk tales are stories designed to teach a specific lesson valued by that culture, they suggest what one should or ought to do, and there is punishment for failure to do what is needed or expected. Legends are stories about heroic and romanticized events that are handed down from previous generations. These stories usually have a kernel of truth, but the events, people, and actions have become magnified and exaggerated to a great extent. Myths deal with supernatural beings, ancestors, or heroes that embody a culture’s ideals or deeply held emotions, and who serve as fundamental primordial types (Hohr, 2000). Bettelheim (1976) notes that “The myth presents its theme in a majestic way; it carries spiritual force; and the divine is present

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and is experienced in the form of superhuman heroes who make constant demands on mere mortals”. The mortals cannot hope to emulate the superhuman heroes, and will always be inferior. Heroes, in myths, have names, do extraordinary things, and are grander than humans can become. Fables are designed to teach cultural values and morals. These stories have a specific point to convey and the listener is supposed to learn that particular lesson. While magic and improbable events are used in fables as they are in fairy tales, these do not stand as metaphors or symbols for the listener’s inner states, they are used as vehicles to get attention and transmit a particular message. Fairy tales are about ordinary people who meet the challenges that everyone faces, and the listener can learn from this, and can aspire to achieve the same tasks or goals. Fairy tales begin with an existential/developmental dilemma that is briefly stated. The central figure(s) is (are) at a threshold where their world is changing (usually their internal world), the future is uncertain, the self is in danger or in a state of confusion, and old answers do not fit the new situation. Sometimes there is a period of wandering where new events, challenges, and enchanted characters are encountered. The central premises in fairy tales are that everyone has difficulties in life, these are unavoidable, and they are a part of the human condition. The struggles, metaphors, and ultimate triumph for the central characters show that it is possible to attain a higher level of self and moral development when one’s inner resources are used in a constructive way, and that problems can be solved if only for the present. This description presents a rationale for why fairy tales can be useful for adults in therapy.

Existential Issues in Fairy Tales Among the many existential issues that are addressed in fairy tales are death, freedom, will as the trigger of effort and seat of volition, the indifference of the universe, struggle and suffering, existential isolation, and meaninglessness. The current pandemic has raised all of these issues, and some have become more visible. It can be very helpful to group members to realize that these issues can only find solutions for the present, are universal, and that they can be expected to reoccur.

Developmental Issues in Fairy Tales Although fairy tales are the focus for this section, many of the developmental issues can also be found in other forms of stories and may be especially relevant for some adults, especially those who are still in the process of growing and developing. Group leaders may find some of these issues applicable to their group members. Among the most prominent issues are the following:

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Developing moral values that apply to the larger society Achieving separation and individuation from parents and further developing the self Understanding how healthy adult narcissism development can be achieved The importance of strong and resilient psychological boundary strength to prevent emotional contagion, exploitation, and manipulation Attaining emotional regulation and control Becoming self-sufficient It is not unusual for group members to have a hazy understanding of where they are developmentally and where they can use more growth. The tales give voice to these and assist members in better understanding of their developmental issues and how these are affecting their current functioning and relationships.

General Fairy Tale Themes and Symbols Following are some general themes found in fairy tales that may also be applicable for other stories. Some general symbols and themes derived from Bettelheim (1976, Brown (1992), and Brun et al. (1993) include the following: Wandering – Latency, becoming ready for the next level of development Forest – Search for meaning, purpose, or direction Helpful animals, non-hostile dwarfs, and other people – Unrecognized strengths and other inner resources Wild animals, birds of prey, and destructive acts by others – Immature parts of self Leaving home – Becoming separated, achieving independence Flowers – The idealized self Water, ponds – Emotional life Church – Sanctuary, safety Keys – Untapped knowledge, resources Turned to stone, stone animals or people – Lack of humanity and connections to others Food – Need for nurturance; overabundance or feasts – oral greediness Simpleton, Witling, and so on – Simply childlike, the reality-based part of self Hostile attacks and hostile people – Ineffective, aggressive, and destructive parts of self that are not yet understood or controlled Sleeping – Suspended animation, latency, waiting Completing Tasks – Achieving self-actualization Jewels – Rewards, success Forester, Hunter – Protector These are only suggestions, and it is highly recommended that group members make their own personal associations for images and feelings that are evoked by the fairy tale or other stories.

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Creative Activities for Stories Presented here are two activities that can be used for deriving the most out of the story. These apply to all forms of stories. The activities all begin with the group leader reading the story. It is strongly recommended that the story be read by the leader and not be a prerecorded video or other transcription, and that the story not be one that has appeared on television or film. It is also recommended that the story or fairy tale selected be short and not take more than ten minutes to read. Read, Draw, and Write The advantages of this approach are many as it provides opportunities for personal exploration of connections to past unresolved issues and concerns, unfinished business, and emotional content. The procedure(s) described will take more time for individual work, but can produce more understanding and insight. Considerable material for exploration in subsequent sessions can be revealed. Two methods are described; one that focuses and guides the writing. Activity 8.1 Drawing and a Fairy Tale (Any story form can use this process.) Directions Gather materials needed for drawing – paper, colored pen/pencils or crayons or felt markers and ensure that members have a suitable surface for drawing. Procedure 1 2 3 4

Read the story or fairy tale. When the tale is finished ask group members to draw two scenes from the story or tale and to give each a title. Regroup and ask each member to present their drawings. Leaders can use the example existential and developmental items to help members gain a deeper understanding of their drawings. Ask members to write a summary statement or paragraph about the experience and their drawings.

Activity 8.2 Writing and a Fairy Tale Materials Sheets of paper and writing instruments.

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Directions Gather materials needed for writing – paper and writing instruments, a suitable surface. Procedure 1 2

Read the story or fairy tale. Distribute the paper and writing instruments and proceed through the following sequence: a

Ask members to divide their paper into three columns and to list all of the following that are in their drawings. Space should permit three columns. Material elements – For example, castles, trees, and the like Actions or implied actions – For example, weeping, fighting People – For example, kings, witches, sons, princesses Animals and insects – For example, ants and birds Immaterial beings – For example, fairies, trolls Feeling tone – For example, danger, relief, happiness

b c

3 4

Beside each item on the list, write an association without thinking carefully, editing or evaluating the association. Ask members to review the two lists and write a summary paragraph about the list of elements and associations that reflects their current life situation, concerns, struggles, celebrations, and so on.

Regroup and share at least one portion of what they wrote for a) to c), or all of what was written. Ask members to do one of the following: a

b

Write the feelings experienced during listening to the fairy tale, and when they were writing and reporting; and relate these feelings to their current life. Verbally report on the feelings and share awareness, surprises, and feelings about the activity.

Scrapbooks Scrapbooking has expanded and is no longer just gluing materials about an event, such as a prom, in a photo book. Although they are also still used in this way, there are numerous enhancements and extensions that provide a creative venue for scrapbooks. Many materials and techniques are incorporated into the display including photos, objects, writings, drawings, poems, and the like. Almost anything can be included in a scrapbook.

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Using scrapbooking as a group activity usually means that members complete their work outside of the group session, and periodically bring the completed work to share with other group members. It is recommended that the group leader schedule these sharing sessions in advance. Another variation is to have an extended workshop session for members to work on their scrapbooks, and this would also be an opportunity to share materials. Advantages for using scrapbooks include the following:






Members can get in touch with forgotten memories, people, events, and so on. Feelings of creativity and inspiration can emerge and be encouraged and supported. More self-disclosure about important parts of oneself can occur as members display their work, and resistance and defensiveness can be reduced. Interactions and emergence of therapeutic factors, such as universality, can be fostered. Exploration of important issues and concerns can be less threatening and allowed to unfold.

Disadvantages are that:






Scrapbooking is a longer-term activity that cannot be completed in a session. Some members may not work well independently. Disquieting memories can be triggered. Some members may not have personal photos from their past. The cost of materials.

Following are some examples of topics for a scrapbook focus, and one example of an activity.


Use photos to tell a story, recall past events and people, highlight life milestones and celebrations, show personal growth and development.

Activity 8.3 The “Now” of My Life Materials A scrapbook (4”  4”, 6”  6” or larger), camera for taking pictures, and scrapbook materials for each member. Each member will need a collection of photos that depict important people, activities, objects, and symbols of desires and wishes at the present time. If photos are not available, or they don’t have the ones they want, they should take pictures for inclusion in their scrapbook. Members may be asked to supply their own materials.

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(Scrapbook materials include card stock, double-sided tape and/or glue, pens for writing, and decorative paper or tape.) Procedure 1

2

3

4

Introduce the activity by noting that sometimes we fail to take full notice of our lives in the present and that the activity is designed to focus their attention on the important things in their current lives without making any judgment. There are no rights or wrongs, good or bad, just what exists in the present. The task is to take photos of objects, scenes, persons, and anything else that represents something about them and their current lives and to mount the pictures in a scrapbook. They are also free to use other objects, such as tickets, receipts, papers, and the like, that have meaning for them at this time. It is helpful for the group leader to have a sample scrapbook page to illustrate what is meant. Distribute the list of materials and give members a timeline for completion, such as two weeks. Tell them to either use existing photos, or to take photos if the desired or needed ones are not available, and to compile them in a scrapbook. They are free to be creative as possible in making the pages for the scrapbook. When members return, have them share their scrapbooks in the group. Focus the discussion on awareness that emerged as they thought about what to put in the scrapbook that depicted parts of their current lives, feelings experienced while creating and developing the scrapbook, and feelings as they talked about the scrapbook in the group. Have each member give a summary statement about their current lives.


Use a collage to express thoughts, feelings, and ideas about a concept, a concern, or to showcase skills or talent.

Activity 8.4 Inventory of My Relationship Attributes Materials Group members will need the following: a scrapbook (4”  4” or 6”  6”, or 8”  8”); cardboard stock, double-sided tape, photos (if desired), images from magazines or catalogues; paper for writing; and a group leader prepared list and description for each attribute. The leader should prepare the list of materials and the list and description of each attribute to distribute to each group member. RELATING ATTRIBUTES AND DESCRIPTIONS LIST

Caring – Conveys that the other person is valued and important. Concern – The welfare of the other person is of importance.

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Tolerance – The capacity to value differences of others from oneself, accepting of diverse opinions, values and the like. Respect – Regarding the other person as unique, separate, and worthwhile. Nonjudgmental attitude – An acceptance of differences (opinion, values, worldview, physical, etc.) without putting a value judgment as to right or wrong, or as being good or bad. Openness – Being receptive to others as they are, and willing to consider differing perspectives. Genuineness – An ability to be real and authentic in interactions with others. Procedure 1

2

3 4 5

Introduce the activity by providing descriptions and examples for each of the relationship attributes. Show members a sample group leader constructed collage for one or more attributes. 2. Ask members to reflect on the relationship attribute as they apply to them personally as they are asked to create a collage about each relationship attribute. Distribute the materials and the timeline for completion, such as two weeks to complete the collages and mount them in a scrapbook. Direct members to create seven collages, one for each attribute, and put them in the scrapbook. The collages should depict their personal attributes. When members return with their scrapbooks, have them show them to the group and talk about what the experience was like for them, such as feelings that emerged. Lead a discussion about the importance of these attributes in interpersonal relations, and where members see that growth is needed or possible.


Use found materials, objects, and recycled materials to be imaginative and creative.

Activity 8.5 Old, New, Different Materials A scrapbook; adhesives; scissors; a set of crayons, colored pencils or felt markers; other embellishments; two or more example pages made by the leader using found, recycled materials, and other objects. Procedure 1

Ask each member to gather a collection of found materials, objects, and recycled materials to use to create a scrapbook that illustrates something

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2 3 4

important for that member. The scrapbook should have six or more pages and can be about anything that member chooses. Show the members the example pages noting the materials used, how they formed new things, and that recycled materials are being used in new ways. Give the members a timeline for completion, such as two or three weeks. When members return with the scrapbooks, have them share and explain in the group just as was done in step 1 with the examples. Explore the process of creating the scrapbooks; what was difficult, what was easy, feelings that emerged, and any new insights or awareness that occurred.


Make a scrapbook to express thoughts and feelings to others. For example, a short scrapbook could express sympathy, thanks, congratulations, and/or when you want to say more and not only use words.

Activity 8.6 A Card Book Materials Small scrapbooks, such as 4”  4”, with about six to eight pages; materials used for constructing collages – cardstock, photos, magazine images, stickers and found objects, a pen for writing. Procedure 1 2

3

Ask members to select a topic or celebration for the scrapbook, such as happy birthday, condolences, or I’m thinking of you. Tell them to construct the six to eight collages for the scrapbook that illustrates the various thoughts, ideas, and emotions around the topic or celebration. For example, a card about thanks could include collages that illustrate caring, gratitude, appreciation, pleasure, thoughtfulness, and giving. The facing page is where the member writes about the thoughts, feelings, and ideas that accompany the expression of the collage. Give a timeline for construction of the scrapbook. When members return with their scrapbook, ask them to talk about their card and the ease or difficulty of construction. Ask if they feel differently about the topic or concept the card scrapbook expresses.

Visual Journaling A variation for journals is the visual journal where drawings, painting, collage, etc., are added to the written words. There can be doodles, tracings, rubbings, and other images that are added to the thoughts, feelings, and ideas that are

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expressed in the journal. These enhancers also are expressions and can be clues to what is just below the level of consciousness at that particular time. When reviewed at a later time, these entries can help the person to better understand past experiencing and its impact on them. Journals can be purchased or made. Books, magazines, sketchbooks, planners, and other such premade items can be used for journals. When books or magazines or other such items are used for the journals, these pages need to be glued together to provide a suitable surface for painting, drawing, and the like. It is important for group members to know that journals do not have to be kept daily, or even sequentially. These are expressions for their experiences and can take place over a period of time. Group leaders should make sample visual journal pages in advance, and also have a variety of possibilities for journals such as a purchased sketchbook. This is a longer-term activity and members should be exposed to how they can easily complete a visual journal that can be meaningful for them. Following are some example topics for visual journals:







Challenging times Healing grief Non-death losses such as during the pandemic Illness and the journey Random and meaningful thoughts, ideas, and feelings Beauty and wonder in my life

You can see that there are many and diverse ways to construct a personally meaningful journal. It can be helpful to consult art journal magazines, books, or from the internet.

Journal Pages There are no restrictions on what can be put on a journal page. A helpful sequence for creating a journal page is to create the background for the page for example, either painting, ink smudging, gluing paper(s), and the like. The next layer can be doodles, torn or cut images or photos, stencils, or whatever is available or that seems relevant. Over that layer is the writing for the expression(s). These can be a quote, a thought, a word, or whatever expression seems relevant. Other possibilities include stamping, found objects, ribbon, stickers, rub-ons, leaves, stamps, and just shapes. Visual journaling can be focused on the past, or the present, or the future. Members may want to journal about a memory that is meaningful, challenges they are encountering, an illness or chronic condition, thoughts and feelings about an important person in their lives, or even hopes and wishes for the future. There are limitless possibilities for the subjects for visual journaling. Members get the chance to explore and expand their thoughts in nonverbal ways that can raise

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awareness, sort through confusing feelings, help focus on essentials and important things or people in their lives and expand ways for their expressions. Following is a procedure that group leaders can find helpful when using visual journals. 1

2

3

4

Calculate the time needed for members to complete a visual journal to determine if there is sufficient time in the duration of the group for them to complete (or almost complete) and to share their journals. Decide on a topic for the journals. For example, a topic during the pandemic could be the impact of the pandemic changes on their lives. The topic should be something relevant to all group members. Gather materials to prepare a sample journal with several complete pages. Doing so will give the group leader an understanding of what materials are needed by group members as well as their availability. While it is possible for the group leader to give members a variety of materials or to have these available for their use, this may not be possible for all groups such as virtual groups where the leader will have to rely on group members to supply their materials. Prepare a sample journal and present to the group. Notice their reactions to the idea of creating a visual journal and be prepared for some resistance as this is likely to be a new and novel activity for them. It will be helpful to explore positive and negative reactions and responses in the group before proceeding with the activity.

Activity 8.7 A Visual Journal Page – My Day Preparation by the Leader Prepare in advance a sample visual journal page around the chosen topic, and a list of needed materials (see the list in Materials). Materials A purchased or made journal, scissors; cardstock, a variety of paper scraps, magazines or catalogues for cutting out images; pen or pencils for writing; glue sticks and/or double-faced tape; sheets of paper; permanent black ink felt markers in fine, medium, and broad points for writing and/or drawing, and a set of crayons, or felt markers, or colored pencils. Additional materials that can be used include stamps and ink pads, stencils, stickers, found objects, ribbon, lace, and so on. Procedure 1

The leader will introduce the activity, show the illustrated page(s), and ask members to prepare a page. Members should have received a list of

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possible materials including what could be used as a journal, in advance so that they are prepared to create a page during the session. It is also a possibility that the group leader will demonstrate the activity during a session and ask members to create a page outside of the session and bring it to the next session to share with the group. Ask members to take a sheet of paper and a writing instrument, and jot down five to seven items about their day such as the following:







Moments of pleasure or beauty Thoughts they had throughout the day Sounds/tastes/sensations experienced Events People they encountered Feelings experienced

They can list all items in one category or spread across categories. These lists will be used to form the written entry for the page later. 1

2

3 4

Next, ask them to select a journal page, and to cut out images from the magazines or catalogues and paste on the page, and/or draw images, doodle on the page, or use a combination of collage and drawing. Remind them to leave room for their written entry. The next step is to write about the items listed in step 2. Use the permanent felt pen for writing as these will write over the paint or ink. Members can write as much or as little as they wish, sentences do not have to be complete, and there are no rules about punctuation. The task is to write about their day. The final step is to include the list on their page. They can paste the list as is, tear around it and paste, or write the items on their journal page. Once pages are complete, reconvene the group and ask members to share something about their pages and the feelings experienced as they constructed the page.

Here are some other possibilities for topics for a visual journal: Closely held values Dreams Meaningful words and phrases Vacation My professional life My inspirational life Gratitude and appreciation

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Flats Flats originated from a book by Jeff Brown, illustrated by Tomi Ungerea (1964) and has spawned a host of variations. Essentially, flats are paper dolls that are drawn and decorated to usually resemble a person and are taken or mailed to various sites where their pictures are taken. Stories can be created around their travels, or a photo or scrapbook compiled, or a book written to illustrate their adventures. Flats are appropriate for all age groups and can be used for a variety of reasons that are explained later in this section. We begin our presentation with a personal story about my experiences with a Flat – Flat Samantha. The evening before I was to leave to attend a conference in Sarasota Fl., my youngest daughter unexpectedly brought me Flat Samantha to take with me on the trip. It seems that it was a class project for my granddaughter, Samantha, where the flat had to travel out of town, and have photos to document her travels. To no avail, I pointed out that we lived at most, ten minutes from three other cities. Flat Samantha was traveling with me to Fl. Most flats have clothes drawn on them but, Flat Samantha wore jeans, a sweater, earrings, and had a silver pipe cleaner belt. Somewhere there was a naked teddy bear. (The belt is mentioned because someone we met said that they wanted a belt like that.) I carefully packed Flat Samantha in a bag and put her with the materials I took on the plane, taking no chances that she might not arrive with my checked luggage. Flat Samantha’s first stop at the conference was the committee meeting where she was introduced, made a member of the committee, photographed with the committee, and photographed with individual committee members. Later, the committee chair showed her pictures to the organization’s board who included them with the conference pictures on the website. Word got around the conference and many attendees asked to see her. We had a short break one afternoon before the evening meeting, and another committee member and I went to lunch and a stroll, taking Flat Samantha with us. We stopped to buy her a necklace at a bead shop. Visualize four grown women carefully selecting four to five beads for flat’s necklace. She was photographed with her new necklace, with a strolling model, and on a bench outside of a shop with a new friend who was waiting for his wife. Flat Samantha also visited the Barnum Museum and was photographed with docents, paintings by masters such as Titian and Rembrandt, and with the rather extensive model of circus life. Everyone was happy to take a picture with Flat Samantha. You probably can tell from my tale that the Flat and I had a wonderful experience. The responses, even from strangers, were very positive and this is what I hear happened with others who participated in an activity with a Flat. I still have the Flat and the pictures. I mentioned before that Flats were usually of people, but I know of at least one occasion when flats were of pet dogs. A colleague who heard my story about Flat Samantha decided to make flats of her pet dogs to send to her stepgrandchildren who lived far away. The children took pictures with their flats (there was a different dog flat for each child), took pictures of the flats in different places, and e-mailed her stories about the flats. Communications and relationships were enhanced.

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Constructing a Flat Templates for Flats and other guidelines can be found at www.flatstanley.com. Following are two activities using a Flat. The first could be used with group members who are deficient in socializing skills, and the second with members who have difficulty verbalizing their thoughts, feelings, and ideas. Activity 8.8 Connecting Materials A template for Flats, heavy cardstock, scissors, and a set of crayons, or colored pencils, or felt markers. Procedure 1

2 3 4

5

Introduce the activity as an activity to foster creativity and imagination. Tell group members what Flats are and provide them with an example of a Flat that you prepared in advance. Distribute the materials and have members cut the Flats out, and draw facial features, and clothes. Members then give their Flats a name. Names are usually the owner’s name with Flat as the first name, such as Flat Samantha. Next, members are to take the Flat three different outside places, such as a mall, where there are people, and photograph the Flat at each site. Other people can also be included. At the next session, have members report on their experiences, and note how the Flat facilitated initiating contact with other people, and how communications were enhanced. Ask members about their thoughts and feelings as they talked with strangers, took pictures, etc.

Activity 8.9 Adventures Materials Same as in the previous activity, with the addition of paper and pencil, or a computer and printer if available to members. 1

2

Introduce the activity as an activity to foster creativity and imagination. Tell group members what Flats are and provide them with an example of a Flat that you prepared in advance. Distribute the materials and have members cut the Flats out, and draw facial features, and clothes.

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3 4

5

Members then give their Flats a name. Names are usually the owner’s name with Flat as the first name, such as Flat Samantha. The next step is to take their Flat to three places in their world, and write a short story (even as short as a page) about each place they stop. For example, if they take the Flat to work, that would be one story. Places could be different rooms in their home, the car, the yard, wherever they go. The stories would be about what the Flat experiences, such as what does the Flat see; what thoughts, feelings, ideas, reactions, and the like does the Flat have. Tell them to try and see the place from the Flat’s perspective. They are free to be as fanciful as they want. At the next session, ask members to share a story and then explore what the experience was like to go to the various sites, and then to write a story.

Summary A wide variety of creative activities was presented in this chapter, and there are even more variations for these activities that could be used to aid group members in their therapeutic journey. Some of the chapter activities may take longer to implement than those presented in earlier chapters and the group leader must be aware that it is still important to allow session time for every member to report even if deeper exploration is implemented in later sessions. The activities are also appropriate for a wide variety of audiences from children to older adults. The activities presented in this chapter can be the primary focus for a session, for all of the group sessions, or as longer-term projects. The eight activities are multilayered, lend themselves to adaptation for particular problems, issues or concerns, and will produce a wealth of information for group members. Many more adaptations for each activity are possible and can be more precisely tailored to the group and its members.

References Bettelheim, B. (1976). The uses of enchantment: The meaning and importance of fairy tales. New York: Knopf. Brown, J. (1964). Flat Stanley. New York: Harper & Row. Brown, N. (1992). Teaching group dynamics. Westport, CT: Praeger. Brun, B., Pedersen, E., & Runberg, M. (1993). Symbols of the soul: Therapy and guidance through fairy tales. London: Jessica Kingsley. Hohr, H. (2000). Dynamic aspects of fairy tales: Social and emotional competence through fairy tales. Scandinavia Psychoanalytic Review, 10(1), 51–77.

Chapter 9

Creative Activities for Some Restrictive and Virtual Settings

Introduction This chapter focuses on creative activities for single session, multiple sessions, psychoeducational, restrictive settings, and virtual groups. These activities can be enhancing for members’ learning, participation, and growth as they can facilitate the lowering of resistance, as well as encouraging members’ interactions. There are some settings where more care must be taken when planning and using creative activities for groups. Restrictive settings include those where the setting puts limits on what members can do such as residential treatment facilities, prisons, and hospitals. Other restrictive settings that also require careful planning because of the constraints are groups held in a virtual setting. Single session groups are those that are self-contained in a particular time frame and where members will only be in group for that one session. Multiple sessions discussed here are groups that may be open groups, where members attend on an irregular basis and where the group may not have specific time boundaries. Psychoeducational groups are usually closed groups with a specific number of sessions, and which disseminate information about an issue, problem, or concern.

Single Session Groups Planned single session groups will have only one session and that session can have varying time frames such as one hour or one day. Planned single session groups tend to be focused on education, skills training, work related topics, and/or brief introductions to a therapeutic strategy. These groups have a narrowly defined purpose and goal, are usually very structured, a significant amount of time is devoted to teaching and dissemination of information, and vary in the amount of time for that single session. Examples for planned single session groups are workshops, training groups, presentations, and seminars for small groups where there is expected member interaction and participation, and demonstrations for a technique or skill. DOI: 10.4324/9781003251989-9

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Benefits There are at least six possible benefits for single session groups: 1

2

3

Receive information. Although it is a given that a single session is likely to be insufficient for many concerns, issues, problems, or for learning a complex skill, there are some positive outcomes for the member(s) who only attend(s) one session. Receiving information is a benefit that should not be underestimated or discounted. Regardless of the issue, concern or need that is the focus for the group, learning is an integral part of almost every group. The information received does not have to be considerable or formally presented. Provide an opportunity for expression of feelings. Group sessions can provide an opportunity for members to more freely express their feelings, especially their intense negative ones. It may also be that these members have no other forum or safe place where these feelings can be openly voiced without censure and the like. While simple venting does not produce insight or learning, it can provide some measure of relief. It can be important for the group leader and members to be accepting of these feelings and not to try to minimize them, ignore them, or in any way suggest that the feelings are wrong. Leaders and members don’t have to agree that the feelings are justified, but neither should they express disapproval. While it would be helpful if that member would return to the group and work on the issue(s) and feelings, that does not always happen so that the moment that the member does express some feelings should be capitalized on by simply listening, reflecting the meaning(s), and/or be provided with an empathic response. Generate new ideas. Many members can be in turmoil when attending the group, especially at the first session where they have the usual concerns about being helped, included, understood, and can be apprehensive about what is expected of them; is the group safe, can the leader and other group members be trusted, and so on. There is so much swirling around in their minds, and there could also be multiple and conflicting feelings that prevent clear thinking. The members can be so mired in their misery that they cannot envision how they can find the help they are seeking. But, even in the first meeting, the group has the potential to help members generate new ideas such as:







Different ideas about the condition, issue or concern that brought them to the group that could be helpful Other sources of help that could be tapped How to access their inner resources of resilience, hardiness, determination, and the like More effective ways to communicate and relate Increase the meaning and purpose for their lives Better coping strategies

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Developing even one new idea can make that session worthwhile for that group member. 1

2

3

4

Become inspired and more hopeful. Inspiration can happen at any time and can come from many sources. While it is difficult to predict what is inspiring for anyone, group leaders can plan for positive activities, interventions, and the like as an integral part of every session. Central to the idea of providing inspiration for the group is the group leader’s ability to model the following: faith in the group and in members that they have the resources needed to grow, develop, and heal; an awareness of members’ strengths that can be emphasized; an understanding of the importance of encouragement and support and the willingness to provide these; and a realistic appraisal and acceptance of oneself as valued and worthwhile. Group members can also provide inspiration, but that cannot be planned. However, the group leader can capitalize on these when they do occur by highlighting them and their positive aspects. Inspiration can provide a measure of realistic hope that can be very helpful. Receive attention. The group is a place where members can receive attention for their concerns and feelings. These can be expressed, explored, and can receive empathic responses. The attentive and responsive group leader does not discount, overlook, minimize, or try to get away from these because of the intensity of the concerns and/or feelings. Group members may not experience this level of attention and caring in their everyday lives. Some may be alone without family or other social support, some may not have family relationships that are constructive and satisfying, and other such personal situations. This lack of acceptance, caring, concern, and empathic responding in their everyday lives can be especially acute if the member’s condition, concern, or issue is chronic and complex. Others can feel helpless to fix it or make it better, and so they withdraw, and the affected person does not get the attention and responding that could be helpful. The commonality that members have in the group around the issue, etc., can provide additional support and encouragement as well as attention because of the shared situation or experiences. Other members can understand at a deeper level some of the feelings and other experiences each expresses and respond empathically. The group provides a climate where attention to members is expected unlike many other places outside of the group such as among family, colleagues, and friends where attention can be brief or even nonexistent. Some attention reassures that there is value of the person. Obtain consensual validation. Consensual validation refers to the agreements among group members that feelings, experiences, reactions and so on are real and are shared. This validation reduces isolation, feelings of being different and/or alienated, and fears of having deep character flaws

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that cannot be “fixed” and are shaming. These states are difficult to endure and are rarely spoken of openly but can have negative and lasting effects on the individual’s self-esteem, relationships, and general functioning. The realization that others share feelings and experiences can be inspiring and comforting. Constraints for Single Sessions The constraints for single sessions are primarily related to the lack of sufficient time for many group and therapeutic factors to appear or to unfold. Group factors such as trust and safety, developing relationships among group members and with the leader, learning to give and receive constructive feedback, constructive management of conflict, and other such factors need time to emerge, and a single session may not be or is not sufficient. Yalom and Leczcz’s (2021) therapeutic group factors such as imitative behavior, socializing techniques, and group cohesiveness are less likely to emerge and be worked on in a single session. These are therapeutic group factors that need time to emerge or be fostered, to be recognized and addressed, and for personal associations or connections to be made by all or most group members. The group leader can be keenly aware that a single session does not provide enough time for group members to explore their reactions, personal associations, resistances, defenses, feelings that are triggered, or to generate complex ideas or practice complex skills. The richness of experiencing that comes with longer term groups is limited or nonexistent. These losses can produce considerable leader frustration. In some ways, the group leader’s frustration and feelings of futility are a major constraint as these can prevent the leader from more fully capitalizing on constructive use of the time that is available. Leaders who are more attuned to what cannot be done, miss opportunities to make the single session as productive as it could possibly be if the focus and attitude were on what can be done, and have a sense of satisfaction and accomplishment for the limited outcomes. It would be much more beneficial for the group and for the leader to take pride and be joyful for the modest or minimal amount of work that is done. SAMPLE SINGLE SESSION PLAN Manage Your Moods PURPOSE: Learn strategies to help manage your moods. OBJECTIVES: Identify sensory distractors, increase awareness of personal strengths, identify two strategies to manage personal negative emotions. TARGET AUDIENCE: Young adults ages 18–14, N=5–8 SESSION: One three-hour session

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SCHEDULE Event/Activity

Time

Welcome, review of agenda and objectives, Q & A, introductions, collaborative goal setting Activity: My Moods – Triggers, Intensity Mini-lecture: Sensory distractors and their value Activity: Sensory distractors Break Mini-lecture: REBT – Perceptions of events Activity: Strengths – Affirmations (Thoughts about self) Summary and closure

30 minutes 20 minutes 10 minutes 30 minutes 5 minutes 10 minutes 30 minutes 20 minutes

Following is a sample mini-lecture for the sample single session group. SENSORY DISTRACTORS INTRODUCTION

Distractors can be a form of thoughts and feeling interruption that take you away from the downward descent into a negative mood. Your attention is shifted from an internal focus to something outside of you that evokes pleasurable unconscious or nonconscious associations and away from the negative thoughts and feelings about yourself that are weighing you down. Those thoughts and feelings become less burdensome as just being away from those negative thoughts and feelings, even for a brief moment, can give you enough space and time for you to decide that you can control things enough so that you do not have to return to your negative mood, nor do you have to immerse yourself in that and be miserable, nor do you have to let the mood become worse and even more negative. DEFINITIONS AND CATEGORIES FOR SENSORY DISTRACTORS

There are six categories for sensory distractors and any of these can have actions that are pleasantly thought provoking or have pleasant associations or memories, and can invite you to linger there for a while and enjoy yourself. There may also be some distractors that tap into more than one category so that you access pleasure on more than one level, the combination intensifies your pleasurable experiencing, and you can be drawn to allow yourself to have a more pleasant mood.


Visual distractors for boosting a mood are sights that bring a smile and you are happy to see it.

When you really see something, your attention is focused on that, your brain is engaged in processing it for identification, and your feelings can become engaged. All of these then lead you to a conclusion that what is viewed is good or bad, pleasurable or distasteful, safe or dangerous, and so on.


Auditory distractors are sounds that capture your attention and interest.

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Are there sounds that bring pleasure when you hear them? These can be used to distract from a negative mood even when they are not spontaneous and you have to seek them out. Focused on pleasurable sounds especially those in your immediate environment.


Tactile or touch distractors are physical objects that are in contact with your skin and the contact produces sensations that are soothing, comforting, refreshing, and evoke other pleasant sensations.

Some tactile sensations are very soothing, or exciting, or provide pleasure in a variety of ways as other sensory experiences can also be triggered. For example, the smooth sensation of chocolate melting on the tongue can also excite the taste sensation.


Olfactory or smell distractors use odors that are in themselves pleasing, or that evoke pleasant memories and sensations.

Scents, or olfactory distractors, are an important part of our lives and there are probably numerous scents that can be pleasurable distractors when you are in a negative mood. Become more aware of pleasant smells around you, and maybe on you such as lotions.


Taste distractors capitalize on the sensations that emerge when something soothes, excites, and is pleasing to your taste buds.

The flavors for these substances are sweet, sour, bitter, umami, or salty. Personal preferences dictate what flavors you find pleasurable, although it seems that most people lean toward favoring sweet-tasting substances.


Kinesics distractors use body movement of some kind to move your attention to using the body, or to become more aware of what your body is experiencing that is pleasurable, or to put you in a place where other distractors can be used and/or experienced.

Movement of the body in a purposeful and mindful way can be a use distractor. The acts of moving, paying attention to what you are doing, and staying aware of how your body feels while in motion can be a powerful distractor. Focus on simple body movements that can soothe, energize or otherwise be actions that serve as distractors. Here is the other mini-lecture. MINI-LECTURE – YOUR PERCEPTIONS

If you were to choose a word for your mood at this moment, what would that word be? If your word describes a negative mood, how do you intend to make it better, or do you want to make it better? Without going into too much detail at this point about why someone would not want to make a negative mood become more positive, let’s just assume that the person has reasons for staying with the negative mood. Some possible reasons for this can be that the person feels unfairly treated, is deeply disappointed, perceives little or no personal control of

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life events, and many more internal and external reasons. For the moment, however, we are going on the premise that you do want to boost your mood to become a more positive one. There are a few assumptions that guide this presentation.


No one strategy will fit everyone or work every time.

What is helpful to you may not work for another person. Indeed, what worked for you at one time may not work for you at this time. This is one reason why you need to have a set of mood boosters, be open to adding new ones, and be flexible in choosing which to use at any particular time. Place and time can also be factors for using effective mood boosters.


Each of you is unique and your mood boosters may or will not fit anyone else.

It can be tempting to try and be helpful when other people are having a negative mood, but giving suggestions based on your personal experiences is not likely to be as effective as those were for you. If you do have an urge to be helpful, try asking the person what usually works for them, and gently suggest that whatever works be tried now, or if that is not possible at this time, ask what other actions the person thinks might be helpful.


You may not be aware of the resources you have or that are around you that will boost your mood.

Many people may not realize or recognize resources they have available all around them and so, fail to use these and remain mired in the negative mood. The sensory distractors are one resource for helping to change a mood.


Your mood boosters come from within you and are not entirely dependent on what another person says or does.

Whatever your mood may be at any particular time, it is related to you and how you perceive and feel about your self. Hence, what works to boost your mood lies within you.


It is possible to catch others’ moods.

Emotional contagion has received a lot of attention and study by social psychology and has documented that you can “catch” others’ feelings. To understand how this works just think about how you feel at the times when you have to interact with someone who is sad, or is mad, or is happy. You may find that you too become more in tune with that person’s feelings and start to have some or all of that feeling too. That process is emotional contagion. This can also be what happens to others when they interact with you when your mood is positive, or negative, or blah.


How you perceive and react to life events has more impact on your mood than do the events themselves.

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Albert Ellis, the originator of Rational Emotive Behavioral Therapy (REBT), has as one cornerstone of his approach that it is not the life event itself that produces the feelings we experience, it is how we perceive and react to these events that produces the feeling(s). This concept may have some validity for understanding how ordinary life events affect our moods. Life events as used here are not disasters, or crises, or traumatic events. While some life events may be unanticipated and/ or distressing, they are put in a category of ordinary life events that happen to almost everyone. One means to addressing a negative mood is to recall positive things about yourself and these are called affirmations. Affirmations are reminders of your positive points, strengths, actions, and the like as a counterpoint for a negative mood.

Multiple Group Sessions Planning for multiple group sessions is presented in Chapter 4. Basics are the following: 1 2 3 4

Specify the goal and purpose for the group. Plan objectives which are expressed as what participants will learn or do in behavioral terms such as identify. Review and plan structural components such as the target audience, number of sessions, and the like. Select strategies such as mini-lectures and activities to accomplish the goals and objectives.

In addition, it is also helpful to plan the individual group sessions so that there is a sequence to promote participants’ learning and growth. Review the schedule for the single session group to see how a session can be planned to fit the time available for it. Group leaders should plan to have some information presented at every session. It can be most helpful if the new information can stand alone by itself and not be built on previous information, that is, the new information should be capable of standing alone. If the group is planned to be only one session, presenting information is a planned part of that group. Psychoeducational groups can also provide opportunities to learn and practice new skills, and group leaders could plan to introduce a different skill each session, such as various communication and relating skills. The introduction of the skill does not need to be formal or structured but can be an informal presentation and an opportunity to practice a new skill. Examples for possible new skills that can be the purpose for the group include the following:





Practicing nonverbal attending skills, such as orienting the body toward the speaker and/or maintaining eye contact Learning to accept compliments without disclaimers or self-disparagement Listening for feelings Naming or labeling one’s feelings instead of expecting others to intuit these

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Responding directly and concretely to others Respectful assertion Recognizing empathic failures

SAMPLE MULTIPLE SESSION GROUP PLAN Following are the components for a sample psychoeducational group on planning a psychoeducational group. TARGET AUDIENCE: Experienced and entry level clinicians, adults, earned degrees, licensure, group leadership experienced. PURPOSE AND GOAL: Presented will be a planning model and process for implementing a psychoeducational group. TIME AND DURATION: Six, one-hour sessions once a week for six weeks PRESENTATION: Remote, via zoom SAMPLE MULTIPLE SESSIONS PLAN OVERVIEW Session

Event(s)

1. 2.

Introductions, overview of process and procedures, collaborative goal setting. Planning the group – presentation of the planning model, discussion, activity. Write a plan for a proposed psychoeducational group that includes all of the components listed above. Planning the group – purpose and goals, objectives. Planning the group – information dissemination pros and cons; readings, media, lecture, PowerPoints etc., most important information needed. Planning the – group activities, cases, role play, etc. Planning for Assessment and Closure: survey, semantic differential, open ended items. Closure process.

3. 4. 5. 6.

Skills Building The other examples focused on personal growth. Following are two examples for skill building activities. Making Connections Materials A preprinted sheet with the following items for each group member, and a pen or pencil for each. “Find the group member who shares your interest in each of the following, write the specific interest in the designated space, such as football for sports, and the name of the person(s) who shares your interest”.

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Sport TV show Kind of music Reading material, e.g. magazines, books Type of food, e.g. a dessert

Specifics

Person(s)

________________ ________________ ________________ ________________ ________________

__________________ __________________ __________________ __________________ __________________

Procedure Distribute the materials and explain the exercise. Ask members to talk to each member separately and see if there is a commonality of interest. Allow about 10–15 minutes to complete this portion. After members resume their seats in the group circle, ask them to share their commonalities, and then ask what was it like to do the exercise, such as “What feelings were aroused as you talked with other group members?” Immediate Feelings Materials A sheet of paper and a set of crayons or felt markers for each group member, and a hard surface suitable for drawing. Procedure Distribute the materials and explain the exercise as follows. “Each of you brought some feelings to the session. Think of three feelings you have at this moment or had as the group began. Select a different color for each feeling and draw a symbol for each of the three feelings. The symbol can be realistic or abstract, whatever you choose”. Allow 10–15 minutes for the drawing. Reconvene in the group circle, share the drawings with as much explanation of the symbols as the member wishes to present. After each member has an opportunity to share, ask them to report on the thoughts, feelings, and ideas they experienced as they thought of the feelings they brought to the group, and as they shared in the group. There are many such skills that could be mini-lessons with practice. This way, even when someone attends one session, there is the possibility that they gain something positive as a result of attending the session.

Groups In Restrictive Settings Introduction Examples of studies on the use of creative activities in a restrictive setting include a systematic review of literature on the use of yoga, mindfulness, and

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meditation in a prison, (Derlic, 2020); yoga (Bartels et al., 2019; Hauzinger, 2018; Norman, 2015); art (Erickson & Young, 2010; Hongo & Valenti, 2015; Gussak, 2019a, Gussak, 2019b; Harun et al., 2018; Hauzinger, 2018; Homeman-Wren, 2021; Kuria & Wainaina, 2019; Regev & Cohen-Yatziv, 2018; Soape et al., 2021; Takkal et al., 2017); horticulture (Ascencio, 2018; Brown et al., 2021; Daphne, 2020; Florence, 2019; Harris, 2022; Moran & Turner, 2019; Toews et al., 2018); music (Chen & Hannibal, 2018; Gold et al., 2021; Hjørnevik - - 2020; Odell-Miller et al., 2019); & Waage, 2019; Hjørnevik et al., 2022; Kokı, animal therapy Collica-Cox & Day, 2021; Corleto, 2018; Dell et al., 2019; Holman et al., 2020; Humby & Barclay, 2018; Rawleigh & Purc-Stephenson, 2021; Stetina et al., 2020; Villafaina-Dominguez et al., 2020). This chapter will present the major concerns for use of activities in most of these diverse settings, and a guide for selecting activities. Major Concerns for Creative Activities in Restrictive Settings Restrictive and virtual settings such as those listed have several concerns in common that should be taken into consideration when planning to use creative activities in those settings. While some of the concerns were presented in Chapter 2, they may be more essential for these settings. The major concerns are privacy and confidentiality, need for documentation and reporting, members’ fears about their personal information, constraints for members’ emotional expression, media access, inconsistent member attendance, freedom from disruptions, members’ emotional expressions, personal boundary concerns, and fear of emotional contagion. Privacy and confidentiality concerns can be of concern to participants as the group leader will most likely be unable to guarantee either. Group members can be rightfully concerned that what they say will be disclosed to authorities and/or others in other settings, to other people, and that they will be negatively affected by the disclosures. In addition, the products of creative activities could be disseminated in some way, or group members do not have anywhere the products can be kept without intrusions by others. While this concern may be present for all groups, it can be much more acute for members in these settings. All needs for documentation and reporting by the group leader is also of concern for some group members as they can fear that what they say and/or disclose will be used in a negative way to impact their wellbeing. Group leaders must be very careful and intentional in their disclosures of what they are required or mandated to disclose and what they are able to keep confidential. It could also be helpful in some settings to remind members that the group leader has the responsibility and requirement to report and document some things. Members’ can fear how the personal information and disclosures will be used against them. It is not unusual for group members to have had experiences where their personal information has been used in a way that is not in their

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best interests. Since this is a group setting where much personal information may be disclosed and some may have to be reported or documented, this fear is not irrational and must be taken into account when encouraging members to talk about their creative products, which can be very revealing. Group leaders are encouraged to emphasize confidentiality even though that may not be maintained by some members, and to let the group members decide on their personal disclosures. In other words, do not push for disclosure. Restricted or inappropriate emotional expression by some members can be anticipated in these settings as some are treatment facilities. Group members may not have learned how or when to express their feelings, may have been criticized for even expressing them, and/or may fear the consequences if they were to express their feelings. Indeed, for some groups it may be best that the group leader minimize asking for feelings, but not dismiss or ignore, feelings expression and keep the focus on the cognitive content. Peer and outside the group interactions cannot be prevented. Even if the group rules ask that exchanges involving group matters be brought back to the group, it will be difficult to enforce that rule. There are several difficulties with these interactions that can affect the group and some members. One difficulty is that the privacy and confidentiality for personal disclosures may be violated without that person’s knowledge. Another difficulty is that the interactions can lead to the development of cliques and these can negatively affect the group’s cohesion. A primary difficulty is the erosion of any trust and safety that was built in the group and members can easily feel that they too will be betrayed. It is for these and other reasons that it is recommended that group leaders are very careful in encouraging members to disclose personal information that could be shameful or that could reflect negatively on them in some way. Group leaders can ask and emphasize that members not talk about other group members or any person disclosures in sessions, but in the particular environment that request may not be respected. Media access may be restricted, which means that some forms of information dissemination may not be available. For example, such a restriction may mean that the group leader could not show a YouTube presentation. Also, if the group leader wanted to make some media-driven materials available for members to view outside of the group session, the equipment and permission may preclude this form of information dissemination. The groups may have inconsistent member attendance for a number of reasons some of which can be related to the type of restricted environment. This can be troubling for the group leader for their planning, especially of sequenced materials, for the development of trust and safety among group members and can delay the development of any group cohesion. Further, the member(s) who may miss sessions can feel that they are not a part of the group, which presents difficulties for interactions and other group processes. When the group leader cannot ensure freedom from disruptions during sessions, this also leads to an erosion or lack of development for trust and safety. In

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addition, these disruptions will negatively affect members’ beliefs about confidentiality and privacy, which can, in turn, make them reluctant to express their thoughts and feelings as well as their willingness to explore their issues, concerns and problems. The group leader can try to lessen the impact of disruptions but should be mentally and emotionally prepared to cope with their outcomes on the group and on group members. Some members may have extremely poor impulse control especially in some of the more restrictive settings, and that indeed may be one of the major reasons that they are in the particular restrictive setting. Group leaders will find it helpful to be prepared to cope with the expressions from these group members that can be inappropriate or hurtful for other group members. While most expressions will likely be verbal, it is not unrealistic for the group leader to be prepared for physical expressions and have a plan for how to manage and handle these. Members’ boundary concerns both physical and psychological, and their emotional strengths and weaknesses will differ, but it can be important for the group leader to be aware of these for each group member so as to help prevent violations or other concerns. Group treatment can build on strengths, allow members to better understand their boundaries so as to prevent violations, and to show them how to capitalize on their strengths. Many of the creative activities in this book are designed to help with all of these. Fear of emotional contagion is usually present in all kinds of groups. Members can fear that they will “catch” other’s feelings and become enmeshed or overwhelmed by these. Emotional contagion is possible especially when some group members may be powerful senders, and others may be susceptible to catching others’ feelings, start to feel these, and worse, be unable to relinquish them. This is one of the reasons why it is important when using creative activities that group leaders ensure that there is sufficient time for all group members to report, and to focus on feelings that emerge for group members.

Use of Activities in Diverse Settings There are three major considerations for using activities in all settings. First, is the choice of type of activity, second is the availability of materials needed for the activity, and the third is the possibility of evoked emotions and members’ capacity to cope with or manage these. The latter is especially important in restrictive settings where group members may be in treatment because they lack the capacity to successfully manage some emotions. It is recommended that group leaders not only consider what emotions may be tapped, but also if members will be able to manage these effectively especially since the group leader may not be able to notice some indices of the intensity for some members. Some activities will be easier to use in the particular restrictive or virtual setting. For example, it can be relatively easy to use writing activities, music, and movement activities in virtual group settings whereas it is much more

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difficult to use art-based ones, not impossible, just more difficult. Some of the constraints about which activities include the rules and regulations in the particular setting such as a treatment facility, the materials that are available, members’ capacity for understanding the instructions for the activity, and the time available for reporting. Let’s review some categories of activities for their ease and difficulty in a virtual or other restrictive environment. Discussed are writing, stories, music, art, and movement. Choice of Activity Writing activities such as Expressive Writing (Pennabaker,1997a,1997b, 1997c) lists, and brief essays can be easily used if group members are allowed to have pencils or other writing instruments and if they have the cognitive capacity to follow the directions. Advantages for using writing activities include that this allows for all group members to participate at the same time around the particular topic, members can be free to choose what they disclose about what they wrote, and the act of writing can help focus their thoughts and feelings. Disadvantages can include the absence of needed materials for a member, their fears about not writing well although this does not matter for these activities, and a reluctance to try and express their thoughts and feelings in this way. The category of stories also includes poems, and cinquains. Chapter 8 presents some ideas for how to use stories and the like and these can be adapted for use in restrictive and virtual environments. The development of the individual products will depend on the tools or implements that are available. For example, if the environment does not permit scissors, then collage may not be an option. Or, if pencils or other writing implements are not available, then writing is not an option for a product. Music activities (Brown, 2013) can be used to energize, calm or to evoke emotions but not for deeper explorations such as those used by music therapists. It is important that the group leader understand what feelings may be evoked by their selection of particular pieces of music as well as knowing a wide range of types of music that can be employed. It may be helpful to consult a music therapist for suggestions of music that can be used by group leaders who are not music therapists. Advantages of using music can be to soothe, calm, relieve tension, promote feelings of wellbeing, energize, and the like. Disadvantages are that the type of music selected may not be pleasing for all group members and that some pieces may evoke unintended distressing memories. In fact, there can be some types of music that are distasteful for some people. Art-based activities may be especially difficult to use in restricted settings as these activities require the availability of art materials such as crayons, felt markers, colored pencils, paint, pens or pencils for drawing activities and glue sticks, scissors, colored paper, and other such materials for collages. It may be

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difficulty for group members in virtual groups to obtain these materials. Another constraint even with in-person groups can be members’ resistance to anything art-based because of the erroneous idea that the activities require artistic talent, and this can be more difficult to overcome in the virtual setting. Some collage activities may be able to be implemented and some suggestions for using these in restricted and virtual groups are presented. Movement activities may be more difficult to implement due to space concerns. Examples of movement activities are dance, yoga, stretching, or even running in place. The intent of movement is to use the body as a means to access feelings, experience different bodily sensations, relax, or energize. However, space is needed for moving around and this may be limited for both the leader and group members in restricted and/or virtual environments. However, there are some that may be used, and ideas are presented later in the chapter. Evoked Emotions There is always the possibility of evoking emotions for members when using activities and that can be the purpose for some activities. There are times when the evoked emotion can be distressful and/or intense and group leaders must stay mindful and aware of this possibility, which is even more important for virtual leadership. Members do not always speak of the distressful evoked emotion and when the session is face to face, it can be easier for the group leader to recognize when a member is distressed or has some other reactions for an evoked emotion. Some visual cues are definitely missing or more easily hidden with virtual sessions. Leaders can make it a part of the expansion phase to ask members to verbalize evoked emotions.

Major Guidelines for Virtual Settings There are numerous studies on the effectiveness of virtual groups for various issues, conditions, and problems and more will be emerging rapidly because of the need to go virtual for the pandemic. Researchers have found favorable outcomes for virtual treatment for panic disorder (Lauckner & Whitten, 2016; Lustgarten, 2017), anxiety, depression (Bischoff et al., 2017; Lauckner & Whitten, 2016; Lustgarten, 2017), PTSD (Lauckner & Whitten, 2016; Lustgarten, 2017), military-related combat PTSD (Acierno et al., 2016; Wierwille, Pukay-Martin, Chard, & Klump, 2016; Yuen et al., 2015), substance abuse (Lustgarten, 2017), chronic pain (Lustgarten, 2017), and obsessive-compulsive disorder (Stubbings, Rees, & Roberts, 2015). Studies for different populations have also found favorable results such as juvenile offenders (Batastini, 2016), parent training (Comer et al., 2017), refugees with PTSD, at risk for suicide (Gilmore & Ward-Ciesielski, 2017) adolescent depression (Kobak et al., 2015) military with depression (Luxton et al., 2016).

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The guidelines for virtual groups begin with the group leader’s adjustment or transition to understanding the benefits and challenges for virtually held group that can be different from in-person groups, and the technology-related planning and organizing tasks. Benefits and Challenges Benefits for members include increased access to services, the possibilities of feeling less anxious or threatened, decreased emotional contagion, increased ability to be emotionally present in session, fewer missed sessions and/or tardiness, increased ability to attend sessions. Increased access to services includes decreased costs to the member such as transportation and childcare, member availability at designated times is easier, members in rural and other such areas can receive treatment that might not be available in their communities, which are definite benefits for the members. This access can also result in fewer missed sessions or being tardy, a reduction in their isolation and alienation, and other positive outcomes. The virtual sessions can also produce less anxiety about being included in the group and how they will be perceived by group members. There can also be a reduction in emotional contagion due to the distance and separation of group members, which could improve their ability to be and stay emotionally present in sessions. There are also some disadvantages for virtual group sessions that include the following: some or all members may lack the necessary reliable technology; their space for attending the group may cause it to be harder for them to ensure lack of disruptiveness and intrusions, which then reduces privacy and confidentiality as well as what they are willing to disclose; technical difficulties that cause frustration during sessions; and other such constraints. In addition, members may experience a lessening of their verbal spontaneity for input and responses, have uncertainty about when to speak, and may find it more difficult to develop a therapeutic alliance. Benefits for group leaders include more assurance of members’ attendance, the ability to provide treatment and care for remote group members and thus increase their access to care, and it may be easier to structure and direct group sessions. (Lopez et al., 2020; Barak et al., 2008) In addition, virtual groups can be beneficial for group leaders in that they can more easily provide sessions in settings such as prisons, residential facilities, nursing homes, and other venues where access to treatment may be more limited. Adjusting to a virtual group environment presents many challenges for the group and may be especially so for using creative activities. Some adjustments include knowing and understanding the technology requirements, how to establish a therapeutic relationship where group members will feel comfortable with disclosing personal material, and the inability to effectively use some group facilitation strategies and techniques. Among the many difficulties that holding virtual sessions present for group leaders include lost behavioral

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cues; as members move and interact less and only their upper body is visible, it is more difficult to scan the group and note members’ reactions. The leader has to look at the camera as part of the better practices for leading virtual groups and this makes it difficult to initiate and maintain eye contact, or to evaluate members’ and the group’s emotional intensity, the reduction of some therapeutic factors, harder to provide group process comments, establishing the therapeutic alliance, fostering member to member interactions, and a reduction of emotional presence. Eysenbach et al. (2004) in their review of online groups found that the online groups tended to develop in the same patterns as did in-person groups. This pattern of development included the period of becoming acquainted, interacting, and setting group norms, and encouraging and supporting group members. They note that groups that had a structured psychoeducational component were more effective than groups organized around a particular condition or problem. Lopez (2020) states that people do find ways to connect in remotely held group settings and are able to interact and connect despite the limitations that these settings present. Planning and Organizing Virtual Group Sessions Crowe (2021) describes the technology requirements and security for virtual sessions that are applicable for virtual group sessions. The technology requirements for both the group leader and members include a computer, camera, microphone, internet connection, and appropriate videoconferencing software. Lustgarten (2017), Luxton et al. (2016), and Swenson et al. (2016) explain that the sessions must be in accord with Health Insurance Portability and Accountability Act (HIPAA) requirements and propose that there be an algorithmic encryption of the video signal to ensure confidentiality. They also state that there should be a backup plan for a technological failure, that the details of the plan should be a part of the written consent, and that it is helpful to have someone with technical expertise near to hand to help manage problems. Much of the success of the virtual group session will rely on the quality of the technology and services such as outdated computers, the reliability and speed of the internet services, and the quality of the audio and video output. When there are continual technical difficulties, computer problems, and/or user inexperience, the leader and group members can become stressed and frustrated. In addition, that means that the focus of the session becomes something other than the designated topic and goal. Another technology-related task is to decide how speaking will be organized so that members can be guided to speak, decrease interruptions, and allow for interactions and discussions. Group members can signal their desire to speak by raising their hand either physically or electronically, It is recommended that group leaders create their space that is seen on the screen by group members to be free from distractions, disruptions, or

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interruptions, to include silencing phone and other devices, and to have this as a requirement for group members. Pay attention to the background for the leader and try to keep clutter, personal objects and the like either absent or minimal, and a digital background is also a possibility. The attention should be on the group leader, not their background. Sessions will be less stressful if the leader and group members can reduce background noises and the easiest way to reduce the noises is to have members mute their microphones. Depending on the level of maturity of the group members they can be requested to mute their microphones until ready to speak, but this then gives some members who already are resistant an excuse for not having input. The group leader should ensure that group members have all needed materials readily available before starting the session. It is very disruptive to the process when materials and the like have to be secured from another location even if that location is just next door.

How to Use Creative Activities in Diverse Settings There are many challenges for using creative activities in diverse and virtual settings and each of these has a unique set of challenges as described previously. In addition to these unique challenges, the group leader has to also consider the target audience and the members’ characteristics, the group’s needs, and the goals for the group so that the chosen activities meet the needs for individual group members and for the group as a whole. Given the constraints and the opportunities for the particular setting, group leaders may want to choose activities from the categories of stress reduction (Chapter 6), managing emotions (Chapter 8), and self-strengthening and personal growth. Some activities from Chapters 4 and 5 may be useful depending on the circumstance for the setting. Group leaders for restrictive and virtual settings may want to be cautious in using imagery, journaling, and performance as they are at a distance where the intensity level aroused may not be easily noticed. Examples of activities for each category include the following: Stress Reduction – Breathing, meditation, exercise, music, and body scans to locate tension and try to reduce that. Managing Emotions – Stories, fairy tales, poetry, music, breathing Self-strengthening – Stories, developing self-affirmations, finding strengths Directions for using activities from each category are included in this chapter and some sample activities.

Directions for Using Stories, Fairy Tales, Poems, and Cinquains There are three methods for using stories – discussing, writing, and drawing. Discussing is used when group members either are not permitted to have the

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materials for drawing or writing, or these are not accessible for all group members. If group members are permitted and have the needed materials for drawing or writing, then either of these may be used. The advantages of using stories, poems or cinquains are that this approach can provide opportunities for group members to do personal exploration of connections to past unresolved issues and concerns, unfinished business, and emotional content at the same time. Directions for Discussion About Stories 1

2

3 4 5 6

The group leader informs the group that the leader will read a (story, poem, fairy tale, or cinquain) and that group members are asked to listen and report as directed. The leader can ask what thoughts and feelings emerged when they heard what was being proposed, and a rating for the intensity from 1 – little or no intensity – to 10 – extreme intensity. (Note: If one or more members have a negative thought or feeling with an intensity above 5, try to explore what seems negative about what is being proposed that aroused their feeling(s). This exploration is more important than proceeding with the reading and discussion.) The leader then reads the item. Ask each group member to report on the thoughts and feelings evoked as they listened. Ask each group member to talk about any meanings, reflections, or memories that emerged as they listened and as others reported. The leader should note and emphasize commonalities among group members.

Summary There can be environments and audiences that are suitable for some activities because of safety concerns for group members, or limitations for the materials used. Some restrictive environments were described, a rationale for choosing activities for the environment and for the limitations of the group members were presented. Specific attention was given to the use of activities for groups held virtually Ten activities were presented for groups held in these environments.

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Erickson, B. J., & Young, M. E. (2010). Group art therapy with incarcerated women. Journal of Addictions and Offender Counseling, (31), 38–51. Florence, S. (2019). Horticulture, hypermasculinity, and mental wellbeing: The connections in a male prison context. Thesis. http://clok.uclan.ac.uk/30740/. Gilmore, A., & E. Ward-Ciesielski (2017). Perceived risks and use of psychotherapy via telemedicine for patients at risk for suicide. Journal of Telemedicine and Telecare. doi:10.1177/1357633X17735559. Gold, C., Due, F. B., Thieu, E. K., Hjørnevik, K., Tuastad, L., & Assmus, J. (2021). Long-term effects of short-term music therapy for prison inmates: Six-year follow-up of a randomized controlled trial. International Journal of Offender Therapy and Comparative Criminology, 65(5), 543–557. Graham, D. J., Stockinger, S., Leder, H. (2013). An island of stability: art images and natural scenes-but not natural faces show consistent aesthetic response in Alzheimer’s-related dementia. Frontiers in Psychology, 4(107). doi:10.3389/fpsyg.2013.00107. Gussask, D. (2019a). Drawing time revisited: The benefits of art therapy in prison. The International Journal of Forensic Psychotherapy, (1), 46–60. www.ingentaconnect.com/con tent/phoenix/ijfp/2019/00000001/00000001/art00007. Gussak, D. E. (2019b). Art therapy in prison hospice. In M. Wood, B. Jacobson, & H. Cridford (Eds.), The International Handbook of Art Therapy in Palliative and Bereavement Care. New York, NY: Routledge. Halkola, U. (2013). A photograph as a therapeutic experience. Lowenthal, D. (Ed.), Phototherapy and therapeutic photography in a digital age (pp. 21–33). New York, NY: Routledge. Harris, C. (2022). Growing gardens in US prisons: The benefits and limitations of prison horticulture programs. (Thesis). https://scarab.bates.edu/envr_studies_theses/267/. Harun, A., Zakaria, R., Osman, A., Ahmad, H., Ali, A., Razak, H. A., & Hamzah, M. H. M. (2018). Islamic art therapy in Malaysian prison. Proceedings of the Art and Design International Conference (AnDIC2016), 191–201. Spinger, Singapore. https://link. springer.com/chapter/10.1007/978-981-13-0487-3_22. Hauzinger, I. B. (2018). Analyzing prison yoga programming for women inmates: A longitudinal inquiry through mixed-methods and participatory partnerships. (Proquest dissertation, California Institute of Integral Studies). www.proquest.com/docview/2109779298? pq-origsite=gscholar&fromopenview=true. Hjørnevik, K., & Waage, L. (2019). The prison as a therapeutic music scene: Exploring musical identities in music therapy and everyday life in a prison setting. Punishment and Society, (21), 454–472. https://doi.org/10.1177%2F1462474518794187. Hjørnevik, K., Waage, L., & Hansen, A. L. (2022). Musical life stories: Coherence through misiking in the prison setting. Crime, Media, Culture: An International Journal. https://doi.org/10.1177%2F17416590211059135. Holman, L. F., Wilkerson, S., Ellmo, F., & Skirius, M. (2020). Impact of animal assisted therapy on anxiety levels among mentally ill female inmates. Journal of Creativity in Mental Health, (15), 428–442. https://doi.org/10.1080/15401383.2020.1729918. Homeman-Wren, B. (2021). Prisoner art programs: Art, culture, and human rights for Indigenous prisoners. Alternative Law Journal, (46), 219–224. https://doi.org/10. 1177%2F1037969X211008977. Hongo, A., Katz, A., & Valenti, K. (2015). Art: Trauma to therapy for aging female prisoners. Traumatology, (21), 201–207. http://dx.doi.org/10.1037/trm0000042.

198 Creative Activities for Some Restrictive and Virtual Settings Humby, L., & Barclay, E. (2018). Pawsitive solutions: An overview of prison dog programs in Australia. The Prison Journal, (98), 580–603. https://doi.org/10.1177% 2F0032885518793951. Kobak, K., J. Mundt, & B. Kennard (2015). Integrating technology into cognitive behavior therapy for adolescent depression: A pilot study. Annals of General Psychiatry, 14, 37–47. https://doi.org/10.1186/s12991-015-0077-8. - - T. (2020). How can music therapy support men at a specialist treatment unit in a prison Kokı, setting in Aotearoa New Zealand. (Doctoral dissertation, Open Access Victoria University of Wellington). https://openaccess.wgtn.ac.nz/articles/thesis/How_can_music_ therapy_support_men_at_a_specialist_treatment_unit_in_a_prison_setting_in_Aotea roa_New_Zealand_/16537212. Kuria N., & Wainaina G. (2019). Re-post tests analysis of using art therapy as treatment for depression: case of Lang’ata Women’s Prison Nairobi – Kenya. African Journal of Business and Management (??????), 5(1), 92–107. http://erepository.uonbi.ac. ke/handle/11295/107388. Lauckner, C., & P. Whitten (2015). The state and sustainability of telepsychiatry programs. Journal of Behavioral Health Services & Research. 305–318. doi:10:1007/ s11414-015-9461-z. Loewenthal, D. (2013). Introducing phototherapy and therapeutic photography in a digital age, Loewenthal, D. (Ed.) Phototherapy and therapeutic photography in a digital age (pp. 5–20). London, Routledge. Loewenthal, D. (2015). The therapeutic use of photographs in the United Kingdom criminal justice system. European Journal for Psychotherapy and Counselling, 17, 39–56. doi:10.1080/13642537.2015.1006132. Loewenthal, D., Avdi, E., Chauhan, G., Saita, E., Natri, T., Righi, R., Tompea, A., Giordmaina, J., Issari, P. (2016). Evaluating the therapeutic use of photocards in European prisons. Counselling Psychology Quarterly. doi:10.1080/09515070.2016.1154018. Lopez, A., B. Rothberg, E. Reaser, S. Schwenk, & R. Griffin (2020). Therapeutic groups via video teleconferencing and the impact on group cohesion. MHealth. doi:10.21037/mhealth.2019.11.04. Lustgarten, S. (2017). Ethical concern for telemental health therapy amidst governmental surveillance, American Psychologist, 72(2), 159–170. https://psycnet.apa.org/ doi/10.1037/a0040321. Luxton, D., L. Pruitt, A. Wagner, et al. (2016). Home-based telebehavioral health for U.S. military personnel and veterans with depression: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 84(11), 923–934. doi:10.1037/ccp0000135. Moran, D., & Turner, J. (2019). Turning over a new leaf: The health-enabling capacities of nature contact in prison. Social Science and Medicine, (231), 62–69. https://doi. org/10.1016/j.socscimed.2018.05.032. Norman, M. (2015). Prison yoga as a correctional alternative?: Physical culture, rehabilitation, and social control in Canadian prisons. In Joseph J., Crichlow, W. (Eds.) Alternative Offender Rehabilitation and Social Justice. Palgrave Macmillan. https://doi.org/10. 1057/9781137476821_5. Odell-Miller, H., Bloska, J., Browning, C., Hannibal, N. (2019). Process and experience of change in the self-perception of women prisoners attending music therapy: The qualitative results of a mixed-methods exploratory study. Approaches: An Interdisciplinary Journal of Music Therapy, 1–29. https://arro.anglia.ac.uk/id/eprint/ 704833/1/Odell-Miller_2019.pdf.

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Pennebaker, J. W. (1997a). Opening up: The healing power of expressing emotion. New York: Guilford. Pennebaker, J. W. (1997b). Writing about emotional experiences as a therapeutic process. Psychological Science, 8, 162–166. Pennebaker, J. (1999c). Psychological factors influencing the reporting of physical symptoms. In A. A. Stone, J. S. Turkan, C. A. Bachrach, J. B. Jobe, H. S. Kurtzman, & V. S. Cain (Eds.), The science of self-report: Implications for research and practice. (pp. 299–316). Mahwah, NJ: Erlbaum. Rawleigh, M., & Purc-Stephenson, R. (2021). PAW-sitive for whom? Examining the treatment acceptability of prison-animal programs. Anthrozoös, (34), 525–541. https:// doi.org/10.31979/THEMIS.2018.0608. Regev, D., & L. Cohen-Yatziv (2018). Effectiveness of art therapy with adult clients in 2018: What progress has been made? Frontiers in Psychology, (9), 1531. doi:10.3389/ fpsyg.2018.01531. Saita, E., Parrella, C., Facchin, F., Irtelli, F. (2014). The clinical use of photography: a single case, multimethod study of the therapeutic process. Research in Psychotherapy: Psychopathology, Process and Outcome, 17, 1–8. Soape E., Barlow, C., Gussak, D. E., Brown, J., Schubarth, A. (2021). Creative IDEA: Introducing a Statewide Art Therapy in Prisons Program. International Journal of Offender Therapy and Comparative Criminology. https://doi.org/10.1177%2F0306624X211013731. Stetina, B. U., Krouzecky, C., Emmett, L., Klaps, A., Ruck, N., Kovacovsky, Z., et al. (2020). Differences between female and male inmates in Animal Assisted Therapy (AAT) in Austria: Do we need treatment programs specific to the needs of females in AAT? Animals, 10(2), 244. Stubbings, D., C. Rees, & L. Roberts (2015). New avenues to facilitate engagement in psychotherapy: The use of videoconferencing and text-chat in a severe case of obsessive-compulsive disorder. Australian Psychologist, 50(4), 265–270. https://doi.org/ 10.1111/ap.12111. Swenson, J., J. Smothermon, S. Rosenblad, & B. Chalmers (2016). The future is here: Ethical practices of telemental health. Journal of Psychology and Christianity, 35(4), 310–319. Takkal, A., Horrox, K., Rubio-Garrido, A. (2017). The issue of space in a prison art therapy group: A reflection through Martin Heidegger’s conceptual frame. International Journal of Art Therapy, 23, 136–142. https://doi.org/10.1080/17454832.2017.1384031. Toews, B., Wagenfeld, A., & Stevens, J. (2018). Impact of a nature-based intervention on incarcerated women. International Journal of Prisoner Health, (14), 232–243. doi:10.1108/IJPH-12-2017-0065. Villafaina-Dominguez, B., Collado-Mateo, D., Merellano-Navarro, E., & Villafaina, S. (2020). Effects of dog-based animal-assisted interventions in prison population: A systematic review. Animals, 10(11), 2129. https://doi.org/10.3390/ani10112129. Wierwille, J., Pukay-Martin, N. D., Chard, K. M., & Klump, M. C. (2016). Effectiveness of PTSD telehealth treatment in a VA clinical sample. Psychological Services, 13 (4), 373–379. doi:10.1037/ser0000106. Yalom, I., & Leszcz. M. (2021). The theory and practice of group psychotherapy (6th ed.). New York: Basic Books. Yuen, E., D. Gros, M. Price, & S. Zeigler (2015). Randomized controlled trial of home-based telehealth versus in-person prolonged exposure for combat-related PTSD in veterans: Preliminary results. Journal of Clinical Psychology, 71, 6, 500–512. doi:10.1002/jclp.22168.

Chapter 10

Creative Activities for Diverse Conditions

Introduction Conditions where creative activities may be helpful include groups for particular conditions such as medical illnesses, emotional disturbances, caretakers for people with certain conditions, support groups, and transition groups, Examples for studies on creative activities used in groups to treat various conditions include the systematic review of group psychotherapy with fibromyalgia patients (Sen et al., 2019), veterans group exercise (Goldstein et al., 2018), and adaptation of MultiFamily Psychoeducational Psychotherapy (MF-PEP) for adolescents with mood disorders (Fristad et al., 2018). The first part of the chapter presents some commonalities among the target audiences even though the conditions addressed may differ. All groups will require basic planning although the strategies will vary because of the needs of the target audience and their ableness to participate in activities. The second part presents guides for activities such as symptom self-management, support groups, and life transitions; sample activities; group factors and activities; and managing difficult member behaviors and activities.

Guide for Selecting Activities Group leaders should expect that members of these groups will likely be very anxious, may be fearful, some will engage in self-blame or in blaming others, may strongly need to be reassured that the outcome will be positive, and some will be depressed. It is important that group leaders be accepting of members as they are, demonstrate confidence that they can learn and change, encourage and support even the smallest attempt and gain, and build a relationship with group members that can be a motivating factor. This does not mean that the group leader should over compliment or flatter members. Rather, the leader needs to be genuine in encouragement and support, recognize efforts expended by group members, point out progress that maybe they don’t see, understand what difficulties or constraints they may encounter, and empathize with them. DOI: 10.4324/9781003251989-10

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Activities should allow for expression of feelings. Use activities that emphasize universality for group members while, at the same time, demonstrate individual personal connections to the material. Activities should be selected based on group members’ abilities – physical and emotional.

Using creative activities that allow expression of feelings, activities that explore current feelings, and the leader and group members acknowledging the validity of expressed feelings can be very helpful as the group sessions may be the only place that some members will feel that it is safe to express some of their feelings. Usually, these groups are homogeneous around the condition. This can be helpful in some ways such as providing some commonality among the members, which can help reduce some of their anxiety; members may be able to serve as models for how they manage parts of the condition, and the material presented applies to all group members. Group members will need to feel that they have a personal connection to the material presented in the group. If they don’t have this personal connection, then they are apt to tune out and resist in other ways. Group leaders can help members recognize their personal connections by linking current and previous self-disclosures, pointing out universality, and by directly asking members to explore what personal connections they may have.

Commonalities for Members of Diverse Conditions Group leaders will most likely encounter groups where members are seeking symptom relief as well as stress reduction, yearning for hope and inspiration, and seeking ways to cope with changes, anxiety and depression, needing to learn to manage their intense negative emotions, and experiencing existential crises. Some members may be experiencing profound grief, loss, and other changes for their lives either because of their condition or as a caretaker of someone who has the condition and are looking for support and encouragement as basic needs. While the conditions for the groups may differ and may call for different strategies, these seem to be the basic concerns that will guide group leaders in their treatment planning.

Basic Guidelines for Selection of Activities The primary guiding principles for the selection of creative activities for groups focusing on diverse medical or emotional conditions are that the personal understandings that can result can guide and direct decisions, choices, attitudes, that in turn, affect behavior in a positive way. There are other outcomes for these groups that are also positive, such as reducing alienation, increasing a sense of universality or similarities with others, providing social support, infusing hope, promoting interpersonal learning, and empowerment.

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Basic planning includes the following:





Consultation with the treatment personnel for the target medical or emotional condition as well as reading the literature about the condition, efficacy of group treatment, and other guiding materials. Establishment of goals and objectives. These should be narrowly defined and presented in terms that are reasonable and achievable. The effect of the condition and/or medication on the ableness of the group members. Outcomes should be capable of being assessed and relevant to the goals and objectives for the group.

Consultation with treatment personnel and gathering information from published studies on treatments and their efficacy is one of the first steps as this provides the basic information to guide the development of group sessions. Many of these groups will have a dissemination of information component and it is essential that this information is accurate as well as informative. The treatment personnel are more likely to have the relevant information such as the target audience’s needs, progress of the condition, and expected outcomes. This step is essential because it is difficult for an outsider, or even someone who is involved, to have a thorough and comprehensive perspective of what the target audience’s needs may be. The professional literature has many studies on the efficacy of teaching how to manage symptoms; prevent relapse or an escalation of the disease, illness, or condition; and other such ways by which the person can help themselves. Some basic information could include the following:









Problem identification – a description of the condition, disease, illness, and so on Treatment options Expected outcomes Precipitating factors when these are important to know to prevent relapse, or from becoming chronic Suggested helping strategies The impact on the quality of life Barriers and constraints Motivation and encouragement factors and strategies

It is very important to take into consideration the ableness of group members to participate in the activity. Ableness would include physical ability such as managing to cut out images or activities that call for physical movement; cognitive ability in order to understand the instructions for completing the activities, or lacking emotional regulation or impulse control; as well as other abilities that may be affected by the condition or medication.

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Families and Caretakers Planning can also include dissemination of information to others such as families, caretakers, and others who interact with the affected client on a regular basis. When facilitating groups for diverse conditions it is important to keep in mind the following: 1

2

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The group member is not the only person who is affected by the condition, topic, disease, and so on. Parents, siblings, spouses, caretakers, and the like also experience some impact. Support and understanding from others in the environment is encouraging and meaningful when they can show some knowledge of what the person is experiencing. Families and others can better cope when they have some knowledge of what can be done, what is not helpful, and expected reactions and outcomes. The families’ and others’ reactions are important components for both the client and for them in reducing anxiety, increasing hope and motivation, and can be empowering. The condition, illness, disease, and the like can cause considerable anxiety for both the person experiencing these, and for those who live with and/ or care for them. Further, when the condition, and so on are not understood well, neither side can cope as well as possible. Relationships, quality of life, self-esteem, and self-confidence, and even their social lives can be negatively affected. So, not only is the affected person experiencing the condition, other significant aspects of their lives can also be affected.

Some conditions, illnesses, diseases, and disturbances have shown improvement for their possessors when psychoeducational groups are conducted for their families and/or caretakers. The affected person does not attend these groups, but seems to gain from others who do attend. Examples for these groups include the following.






Cancer (Bultz et al., 2000; Landry-Dattée et al., 2000) Alzheimer’s/Dementia (McFarlane & Sanders, 2000; Herbert et al., 2003) Eating disorders (Uehara et al., 2001) Schizophrenia (Dyck et al., 2002; Vallina-Fernandez et al., 2001) Psychiatric disorders (Cuijpers & Stam, 2000)

Families and caretakers reported less stress and burnout, and the patients had better compliance with medication and following treatment plans, less relapse, and for some, fewer and shorter hospitalizations. McFarlane (2002) in the book, Multifamily Group Treatment in Schizophrenia, describes the effective groups as “those that can make the transitions from biological/pharmacological to psychological and social levels” (p. 117). Most

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effective is when the group process can assist in changing attitudes, produce a climate and social environment for recovery, instill motivation and hope, and encourage the development of a social network. This can be applied for other groups for families and caretakers. The cognitive material focuses on helping families and caretakers understand subtle and overt symptoms; the effects of medications; usual ways that families and others are affected; how stress affects the patient and others in their world and also impacts healing and/or recovery; coping and management strategies; and the prognosis. This understanding is critical to gaining a sense of mastery and empowerment, expectancy, and renewed commitment.

Guides for Activities: Symptoms and Self-Management Self-managing or coping skills can be very affirming for group members of these diverse groups around conditions. Activities can be used to teach group members strategies that will assist them in adapting to a significant change in their lives, such as an illness, condition or disease. It will not be unusual for members of groups around conditions to be depressed, despairing, in shock, angry, and/or experiencing other intense negative emotions. Thus, group leaders need to be emotionally prepared to encounter resistance, defiance, and displacement of anxiety and anger, which is usually displaced on the leader. Whatever the group’s main purpose is, it would not be unusual for group members to have some intense emotions that they may find difficult to express, or to not have a venue for expression, or for some to not admit their feelings. Planning for these groups involves a lot of consultation and research because many group leaders may not be familiar with the condition, illness or disease that is the focus for the particular group. Further, cultural differences can also play an important role in planning for what information to present, and also a recognition that the western medical model is not the only model, and some group members may have a different model or perspective. Accurate information and an openness to understanding alternative perspectives are critical. Group members can usually have the following symptoms:








A common condition, illness, disturbance, or the like Intense and uncomfortable affect The strong desire to “fix it”, make it go away, and a denial of its severity Fears about the group, the condition, and the future Anger about the circumstances that brought them to the group whether that is something they did to themselves, something others did, or just fate Shame at not being able to prevent or “fix it”, or not being good enough Resignation, depression, and/or despair

In addition to the above, some members will be in physical pain.

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They are seeking symptom relief and the group can help them learn selfmanagement of symptoms; adapting to changes in functioning, lifestyle, and relationships; possible impairment of physical, psychological, and mental wellbeing; forestalling the deterioration of the quality of life, acquiring adequate insurance and personal funds; moderating the effects of medications; and so on are some topics that can be expected and helpful for these groups. Empowering and encouraging members to be as proactive as possible can assist in adapting, recovery, and healing. The group leader and members’ reactions to activities are an important consideration especially during the reporting and exploration phases. Providing feedback about reactions is extremely important, and the group leader has to manage this carefully so as to not appear as critical or blaming. Some people tend to hear others’ reactions as being negative or that they are wrong or that their performance is inadequate. These people do not hear others’ reactions as that person’s observation, they hear it as an attack on their self, can become hurt at the thought of being wrong or inadequate, become defensive and/or defiant, and not participate as willingly or fully. The leader can use the following steps for giving constructive reactions and/or feedback that can be used and could be taught to group members. 1

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Begin with a positive comment about the member’s product or performance. One positive outcome for doing so is that the comment can be an observed strength that the member may be overlooking or minimizing. Do not use language that says or suggests that the group member has a fixed trait, which is something the person cannot change. Also refrain from using words that suggest right, wrong, good or bad. Use words like better, more effective, and so on. Check to see if the reaction/feedback was understood as it was intended. It can be easy for a receiver to misunderstand or distort a message, especially if the receiver fears shame, blame, or guilt for not being “right” or for making an error. Stay in touch with the impact of the feedback on the receiver, and stop if the group member seems to withdraw, their emotional intensity seems to become more intense, and/or their reactions or answers are defensive.

It can also be helpful to have a process to implement when a group member falters, goes in the wrong direction, seem to become paralyzed, withdraws, or uses inappropriate disclosure or behavior. Begin by asking that group member what they were experiencing at the point where they faltered or withdrew. Try to get the person to express their thoughts, feelings, and ideas at that particular time. The answers often provide clues to what triggered their response. Examples of such triggers include the following:

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An inappropriate self-absorbed focus with too much concern about not making a mistake Fear of offending or injuring another person, or of making a situation worse Lack of knowledge Anticipating the future instead of staying in the present Jumping to conclusions before having enough information Mind-wandering, zoning out, and other lack of attention behavior

Once the leader has some notion of what was taking place for the group member at that time, it becomes easier for the leader to guide the member through their reactions, such as withdrawing, future.

Support Groups Brown (2005) presents an overview of the multiplicity of support and therapy groups divided into three categories: medical illness; psychiatric, psychological, and emotional disturbances; and recovery. These are termed support and therapy related because they are defined as such in the literature. These groups are usually defined as a major part of treatment for a condition, disease, illness, disturbance and so on, but there are other parts or phases in the treatment plans. Whatever the topic for the particular support or therapy group is, the group leader can expect to encounter strong emotional reactions that can be open, hidden or suppressed, and/or denied. The emotional component becomes very prominent, and there is the possibility that the cognitive component will become minimized, and that should be avoided because a major goal is to educate group members about the condition, illness and so forth. Leaders can expect existential factors to also be an important part of support groups as well as the therapy groups around conditions. Leaders should be prepared to lead discussions on topics such as death and the unfairness and indifference of the universe to their pain and suffering, and/or to deal with these as they emerge in the group. These factors are the “elephant under the rug in the middle of the room”, especially if the members do not mention them. There can be considerable unspoken fear shared in common by group members around existential factors.

Life Transitions The two categories for life transitions groups are general, where the topics refer to expected life situations and events that can have a significant emotional component associated with them, and specific, where the situations and/or events are not universal but have become rather common in today’s society and these can also have strong emotional content. These groups usually have the following purposes and goals:

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Reduce uncertainty and ambiguity about the transition Provide a venue for exploring experiences and expression of feelings Reduce feelings of alienation and isolation Introduce logical and rational thinking instead of concentrating mainly on feelings Eliminate blame and criticism of self and of others Suggest and implement coping strategies Provide accurate and valid information

General life transition groups include groups formed around expected developmental issues, such as forming intimate relationships, grief, and loss, dealing with aging parents, employment and unemployment, retirement, adolescent physical and emotional changes, and other such issues and concerns. The emotional component can be very intense for some of these groups, such as what happens with the topic of unemployment, but many of them will be more cognitively focused than most other psychoeducational groups. Specific life transitions groups are focused on a particular life transition that is expected, but does not occur for everyone, or for most people. Topics addressed for these groups include divorce and children of divorce, dealing with an abusive partner, displaced homemakers, racial and cultural identity, independence for people with disabilities, and aging. The members in these groups are usually experiencing the effects of the condition and so on, and there can be considerable affect experienced and expressed in these groups. The life transitions can bring back unresolved issues around family of origin and other past experiences, unfinished business, and other developmental issues. These groups may have considerable information to be disseminated, but the affective part of the group experience should not be neglected. Sample Activity Participants are presented with a list of change strategies to rate from 1 – not at all doable, to 10 – very doable.





The ratings discussed in the debriefing period. Group members report how they might or could change. Members are asked to commit to one to two changes that are of high priority for them. Weekly reports to the group on progress, constraints, and so on.

Techniques that may be useful for this group include teaching relaxation techniques, cognitive self-affirmations developed as encouragement and support, using members’ positive experiences with change as models, and role play getting started on lifestyle changes. Developing specific and individual

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action plans that prioritize actions, identify constraints and barriers, and with behavioral indicators for progress would also be helpful. Visualization – soothing oneself, Butterfly hug Affirmations – personal qualities (bookmark?) Collaborative – squiggle, descriptors, illustrate symbol for members Six words – gratitude, regrets, and disappointments for oneself A wish, a hope, a thought, and affirmation (one word for each – realistic, projected outcome) Daily appreciations – mediations – visualize, name, moos, garland Envelope – inner and outer self; messages to different parts of self Stories – hear and draw or write Drawing Instructions 1 2 3 4

Gather and distribute materials needed for drawing. If this is virtual, ask members to get the materials. Read the story or poem or fairy tale and ask group members to draw two scenes from it and to title each drawing. Ask members to show their drawing. Do not explore at this time. Next, ask members to make a personal association for each item in the drawing – objects, buildings, people, animals etc. For example, an association for a key could be education or learning, for a tree an association could be stability and strength. The associations should be by that member only. If they cannot think of an association, have them move on to the next item.

Writing Instructions 1 2 3 4

5

6 7

Gather and distribute materials needed for drawing. If this is virtual, ask members to get the materials. Read the story or poem or fairy tale. Ask group members to visualize a scene from what was read and to make a list of all of the elements in the scene: animals, plants, people, actions, and the like. Next, have them write a word or phrase about themselves that comes to mind as they think about the particular item on their list. For example, if they had a flower on their list, their personal association might be “growing and thriving”. Ask members to read to the group their lists, associations, titles, and their associations. Do not explore the meanings unless the member initiates the exploration. Finally, ask members to write a summary of the lists and its associations with their current life. Conclude by asking members to give a word or phrase that sums up the experience for them.

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Activity 10.1 My Mood Trigger(s) Materials Sheets of paper and a pen or pencil or a suitable digital device. Procedure 1 2 3 4 5

Gather materials and find a place to work with a suitable working surface free from intrusions and disruptions or distractions. Begin with an awareness of your present mood and record this with either a word or phrase. If your mood is positive, record your feelings at this time. Then recall your most recent negative mood and the feelings that accompanied that mood. If your mood is negative at this time, record the feelings you are experiencing. Use either the negative mood in step 4 or step 5, try to identify when the negative mood began. Record your answers to as many of the following as possible:






6

7 8

9

What day of the week, or time of day, and/or time of year did you become aware of the mood? What were you doing and what were you feeling about yourself? Who was present or were you alone? Identify three activities you did prior to the mood. How satisfied were you with your life overall at that time?

Review the answers you wrote for step 5 and determine if there was a feeling, thought, action or person(s) that was the defining point for your negative mood. For example, you may have received bad news, an appliance may have needed repairs, you clashed with a peer or family member, or the mood just seemed to appear out of nowhere. If you did identify one or more triggers, now think back over a longer period of time and recall if something similar triggered prior negative moods. If you could not identify a specific trigger, continue to try to identify what triggered your mood. For example, can you recall what events were happening to and around you at that time? There could be a collection of events that caused the triggered mood; or, were you ruminating about your satisfaction with yourself, your achievements and the like? Or, were you thinking about your failures, lost opportunities, lack of options or alternatives, or fear of possible future events. If you have some ideas about your trigger(s), record these.

Let’s begin this journey and exploration of your mood boosters with an exercise about your current mood.

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Activity 10.2 My Current Mood Materials A sheet of paper and a pen or pencil, or a suitable digital device. Procedure 1 2

3

Find a place to work that is free from distractions and disruptions. Sit in silence and gather your thoughts to focus on the exercise. Let your thoughts focus on your current mood, and record all of the thoughts, feelings, and ideas that emerge even if some are vague, or just fragments. Do not edit or change what emerges as you think, and do not try to rationalize or evaluate them, just let them emerge and record them. When you complete your list, review what you wrote and try to capture the essence of what emerged in six words like the following: Gloomy sad, helpless unable to help Pleased satisfied, powerful Making a difference Excited Apprehensive, enthusiastic a major event

Activity 10.3 Pleasant Sights Materials A sheet of paper and a pen or pencil, or a suitable electronic device for writing. Procedure 1 2 3

Make a list of all of the sights that bring you some pleasure. Write your list as quickly as you can without editing. Once you find that you have slowed down thinking of these, sit back and close your eyes so that you can reflect and maybe add more items to your list. Next, return to your list and rate the level of pleasure the sight brings using a scale of 1 (a little pleasure that is transitory) to 10 (a lot of pleasure that lingers).

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Next, rate the availability of each sight when you want or need a visual distractor. For availability use the scale of 1 (somewhat unavailable) to 5 (almost always available). Finally, write a summary statement or paragraph that describes your feelings as you think about any or all of the items on your list.

Activity 10.4 Skin Distractors Materials One or more sheets of unlined paper, a pencil or a pen, and a set of colored pencils or felt markers or crayons. Procedure 1 2

3

4

5

6

Find a place to work that is free from distractions and interruptions, and that has a suitable surface for writing and drawing. Sit in silence and recall being aware of something pleasurable against your skin. This could be a loving touch, a needed hug, becoming clean, a soaking bath, or anything that comes to your mind. Once you have the scene or an item emerge, use the colored implements to draw the scene or item. When you finish the drawing, use the pen or pencil to record your thoughts and feelings as you drew the scene or item, and now, as you are reflecting. Work quickly, do not edit or evaluate, just draw and write. Steps 1–3 can jump-start your thinking about tactile sensations. Now, select another sheet of paper and make a list of all pleasurable tactile sensations you recall. For each item on your list in step 4, write an association for it – for example, how the silk scarf from your new outfit felt on your neck. Try to have at least one association for each item on your list. The final step is to place a check by each item that could be readily available as a distractor. As noted before, some items may take effort on your part to get them.

All of the usual senses have been described for distractors and you are encouraged to explore the usefulness of each category for you, and to try some activities for each category as well as creating some new activities. Activity 10.5 Beginning to Be Mindful Materials No materials are needed.

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Procedure 1 2

3

4

Find a place that has comfortable seating where you will not have intrusions or interruptions. Seat yourself and look around your space and find an object to focus on and explore. If the object is small and movable, pick it up and look at it. If the object is large and/or immovable, just examine it in detail. Either way, do not make any value judgments about the object such as, good or bad, right or wrong, or worthwhile or useless. Just observe it as it is. Whichever object you choose, explore its characteristics as if you will need to describe it to someone who is unfamiliar with it. Your exploration questions can be its size, weight, its color(s), odors if any, transparency or opaqueness, purpose, and other such characteristics. Notice as many details about the object as possible. When you are ready, come back to the present and notice the following:





5

Approximately how much time passed How your body feels If your breathing is calmer than when you started the exercise How or if your feelings or thoughts changed

If you are keeping a journal as suggested in Chapter 1, you may wish to write about this experience.

It may be difficult for you to focus and concentrate for any length of time at first, and you may have intrusive thoughts. Be patient as you may have to practice this several times before you can spend more than a couple of minutes being mindful. I recommend that you practice exploring an object every day for a week and see if the time you remain involved with it becomes greater. You can also practice the procedure without having an object. Just sit in silence, don’t try to think about anything, empty your mind, and then see how you feel afterward. Activity 10.6 Handling Intrusive Thoughts You have a lot on your mind and many tasks to accomplish. Part of your negative mood may result from intrusive thoughts that you find difficult to relinquish. What follows is a procedure that can help you manage intrusive thoughts whether you are trying to be mindful, or at any other time. Steps 1 2 3

An intrusive though emerges and you want to get rid of it. Pause. Do not try to block the thought, or to try to think of something else.

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Don’t examine the thought as that can lead to the depressive spiral. Focus on the thought and visualize it as an image, e.g. a crumpled piece of paper, a used tissue, a discarded grocery bag, any image you choose. Once you have your image of the intrusive thought, then visualize it moving away from you on its own for the present. You can use one of the following as an image for its moving away:







As a puff of smoke Riding off on a balloon across a field Drifting on a leaf in the wind Riding the waves toward the horizon On a twig drifting down a stream Being flushed down a drain

You are ridding yourself of the thought for the present time. If it is an important thought, it will return on its own and you will be in a better place to deal with it. A bonus is that your mood will be boosted because you did not follow the intrusive thoughts. Activity 10.7 My Special Place Directions are provided for three different ways to complete the exercise and a list of materials for each. Choose the method you feel best suits you. Materials Drawing – A sheet of paper and a set of colored pencils or felt markers, or crayons and a pen or pencil for writing. Writing – A sheet of paper and a pen or pencil or a suitable digital device. Photo – A photo of a place that gives you the feeling of a retreat or happy place or sanctuary, a sheet of paper, double-sided tape, and a pen or pencil. Or, if the suitable computer and software devices are available, the photo and exploration can be completed using these. Procedure 1

2

Read the first two steps before beginning to work. Gather materials and find a suitable place to complete the exercise that is free from distractions and interruptions. Close your eyes, sit in silence and try to clear your mind. Let an image of a place or setting emerge that gives you a feeling of being safe, pleased, and nurtured. Stay with that image as long as you like, noticing as many details of the image as you can such as colors, sounds, shapes, actions, objects, and the like.

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3

When you are ready, open your eyes and do one of the following: For drawing: Draw the place or setting. For writing: Write a complete description of your image. For the photo: Use the double-sided tape and tape the photo to the paper and write the details you recall when you closed your eyes. If you are working on the computer, use the software to paste the photo on a page and follow the photo directions in step 3.

4

Next, make a list of the feelings evoked as you imaged your retreat, happy place or sanctuary, as you wrote or drew or on the computer, and now as you look at your product. You now have an image that you can access whenever you feel a negative mood emerging or when you realize that one is getting worse. Just a brief respite can be enough to boost the mood.

Happy Moments Few, if any, people can be happy all of the time, but all of us can experience happy moments. What is proposed here is that you begin to collect some happy moments to return to when you have the blues, blahs, or grumpies. Happy moments lift spirits, provide hope, increase feelings of physical wellbeing and has other such positive benefits. Like moods, these moments are usually brief and transitory although we may wish them to be more lasting and have sustainability. Prevention and intervention of your negative moods can be enhanced when you have and revisit some happy moments. What can constitute a happy moment for you?












An unexpected recognition of an accomplishment Being present when a family member does something important or makes him/her happy such as a birth, wedding, or receiving a sport or academic award When your solution to a problem works or produces a positive result Hearing that you did get the job, raise or promotion Being recruited for membership in something you want or feel is important Seeing your creative product on display Finishing a complex, long involved project A gift from someone significant to you Playing The realization that you are getting better, recovering, or growing Feeling at peace with yourself

No one but you can define your happy moments and these are just suggestions to get you started thinking about what gives you the feeling of happiness if only for that moment or a short period of time.

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Reflection: What do you do when you are happy; smile, twirl, dance, sing, whistle, or the like? When was the last time you did any of these or had a happy moment? The next exercise can help get you started on your collection of happy moments to have your collection of happy moments to revisit when you have or start to have a negative mood. Activity 10.8 My Happy Moments Materials Three 3”  5” index cards and a pen or pencil. Procedure 1

2

3 4 5 6

Find a place to work that is free from distractions or interruptions, and that has a suitable writing surface. Sit in silence and reflect on the present and your recent past. As you focus on your present (however you choose to define it), recall the moments when you felt happy. Do not try to focus on “being happy” as that is more prolonged and has many complex variables. What is called for here is a very brief period where you were genuinely pleased, appreciative, happy, and the like. Take one card and label it “Present”. Then list those happy moments you had during this time period. Try to list eight to ten of these moments on your card. Repeat step 2 for your recent past such as the previous one to two years. Repeat step 3 and label another card “Recent Past” for your recent past happy moments. Put the two cards side by side and read what you wrote, noting any patterns you see for these happy moments. Examples for patterns may be like the following: Your physical state Time of day or week Visual sights involving color Your movements Another person or a particular person Finding something – lost, a solution, a new thing Alone or with others At home, or at work or somewhere else

7

Label your third card “My Patterns” and list all of the patterns you see from the other two cards. Once you have your pattern(s), write a sentence that describes how you can maximize the possibility of experiencing a happy moment. For example, if part of a pattern was your physical state, you can maximize that by noting that you could eat more regularly, or

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get more sleep, and/or exercise more often to keep your physical state at its optimum. Do this for each pattern you identified. You now have a collection of happy moments, the pattern for these that fit you, and may even have some thoughts for how to increase these. Keep these cards where they are readily available, First, we’ll focus on some common fantasies that may not be helpful and that may contribute to a negative mood. Activity 10.9 Fantasies Materials A sheet of paper and a pen or pencil for writing. Procedure 1 2

Either reproduce the following scale or make a list of the number for each item. Use the following scale to rate the extent to which you have the described fantasy. You may need to be open to the possibility, even if you don’t like to accept that you do have this wish or desire. 1 2 3 4 5

– A very strong wish or desire / I have this wish or desire very frequently. – A strong wish or desire / I have this wish or desire frequently. – A moderate wish or desire / I sometimes have this wish or desire. – A mild wish or desire / I seldom have this wish or desire. – Not like me at all / I never or almost never wish or desire this.

Common Fantasies

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Winning a large lottery. Achieving fame and fortune. Another person will change as I wish them to change. I’ll never show signs of aging, become ill or the like. I have a talent or ability such as being a top athlete, an artist, being an inventor; but I just haven’t worked on it. Everyone will admire and envy me, or they should do so. I must never make a mistake. Others, such as capable adults, need me to take care of them. I must be perfect. Others should do what I tell them to do. I can do everything I want to do and do it well all of the time. I am entitled to get and have what I want. I must be powerful and win all of the time. Others should have my needs and desires as their priorities, and ensure that these are fulfilled.

Rating

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Activity 10.10 How Am I? Materials 5”  8” index cards, a set of crayons, or colored pencils, or felt markers for each participant, and a pen or pencil. The group leader should prepare in advance an example of possible feelings on a large sheet of newsprint to display. Possible feelings could include apprehension, dread, excitement, sadness, hopeless, envy, anger, numbness, shame, incompetence, frustrated, resentment, and so on. Also prepared in advance is an example 5”  8” index card with colors on it to fill up the card, such as triangles or squares of color, with the name of the feeling depicted written in the color. Procedure 1

2

3 4 5

This is an exercise to use after members have introduced themselves. Distribute the materials and ask members to use the colors to label their current feelings as they begin the group experience. Note that many people will have several feelings, but that each feeling may have differing intensity. Instruct them to select the colors that best identify the feelings they have at the current time, and to construct their card of feelings with the names of the feelings in the color chosen. They can refer to the example card for clarification. After the cards are constructed, ask group members to give their cards a title. Have each member display and describe their cards, noting similarities in feelings identified, and color choices. Explore the experience by asking them the following:





Was it easy or hard to identify their current feelings? What was it like to sort through the different feelings, and select colors? What feelings emerged as they completed the exercise? When they displayed their cards? What similarities have they identified among group members?

Group Factors: Inclusion It can be easy for some people to feel excluded in a group, and it can be easy for the group to exclude one or more members. Cliques and subgrouping are two examples of the group excluding members. However, the group is unlikely to become cohesive unless all members feel included. The group leader has to maintain an awareness of members feeling isolated, alienated and/or excluded; and the group’s behavior that excludes one or more members, such as what can happen with an identified patient, or the member who is scapegoated.

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Helping members to feel included involves giving them attention, soliciting and valuing their input, listening and empathic responding, and respecting their differences while emphasizing their similarities with other group members. The last point is especially important as it can be easier for the group to highlight and focus on differences than it is to recognize meaningful similarities. Visible differences, such as age, or skin color, or accent, or disability, can produce feelings of being different, or the member having the characteristic(s) can be responded to in a different way than for other group members, or the member can be put on the spot by having questions asked about race/ethnicity, heritage or national origin, or other such questions that highlight their “difference”. In addition, there can be hidden or masked characteristics that can cause someone to feel different or excluded when the members or the leader makes comments that touch that characteristic and, because the characteristic is not obvious or visible, the affected group member can be put in a double bind where they can be unsure whether to become visible or to stay hidden. An example would be socioeconomic status that is not usually visible in the United States from dress, language usage, accent, and the like. Having a hidden characteristic that is discussed without knowing that a member has that characteristic can produce feelings of being excluded for that person. Use of a creative activity can assist with promoting inclusion when all members report on their products, the responses and comments each member provides are invited and directly responded to, and linking is used. This can be easier to accomplish for all group members through reporting, exploration, and expansion of their creative activity products. When the group expectation and climate are set so that every group member has an opportunity to present their product; express thoughts, ideas, and feelings; have comments and responses responded to directly and with respect; be invited to have input; and other such actions, the outcome can be feeling included. Promoting feelings and actions of inclusion is necessary so that group members can feel the group to be welcoming and caring with opportunities for members to experience being a part of an experience that transcends the individual. An introductory exercise that may facilitate inclusion follows. Activity 10.11 Meet and Greet Materials None Procedure 1 2

Divide members into dyads and have them move their chairs to face each other. Instruct the smaller groups to introduce themselves to each other by disclosing something important about themselves, and a goal they have for

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5

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the group experience. They are given three minutes to complete this phase, and then they move to face another person. Repeat step 2 until all members have had an opportunity for introductions. Reconvene in the group circle and explore what the experience was like with an emphasis on the feelings aroused, making sure that every member has a chance to report. Ask members to share with the group the goals they shared.

Encourage Emotional Expression Creative activities can teach group members how to gain greater awareness of their feelings, to understand their intense negative feelings so as to reduce the fear that can surround these, learn more appropriate ways to express their feelings and have this accepted by others, to identify gradations of feelings so that subtle and lesser intense ones are consciously experienced, and to manage and contain their feelings. Awareness of what is felt can be taught and the group can be a safe place to focus on and practice immediate feelings. Some people recognize what they were feeling at a particular time only in retrospect. Others, because of family of origin and other experiences, learned to repress or suppress their feelings because of negative consequences, and now cannot access these. Even some people who have some awareness of what they are feeling can grow in their awareness. Creative activities can facilitate increased awareness with their stimulus procedures. Intense negative feelings such as anger, fear, and shame can be scary when experienced and thus, can be denied, repressed, displaced or expressed in inappropriate ways. These feelings are also detrimental to having and sustaining positive and satisfying relationships when they are not understood by the person experiencing them, and/or expressed in ways that are destructive to their relationships. Developing an understanding of why these feelings emerge, their triggers, and what they are responding to, either from the external event or from an internal state, can produce considerable self-understanding. The outcome can be a reduced need to have these feelings in response to perceived threat whether an internal or external threat. Group members can be taught about their feelings to help them better assess the validity of the perceived threat that produces the feeling(s). Learning more appropriate ways to express feelings can be taught and learned in the group. Not just word choice, which can be important, but also learning to consider the importance of staying in contact with the responses and reactions of those who hear and receive the impact of the expressed feelings. Appropriate expression of feelings incorporates the setting where speaking of what is being felt takes place, the target receiver or audience, the internal need or impetus to speak of the feelings(s), immediacy and control

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where the intensity may suggest a loss of control, and the motive or intent. The entire process of a creative activity promotes the learning needed for appropriate emotional expression. There may be group members who have never learned to identify graduations of feelings, so they are only aware of when they experience the intense level. For example, some people are not aware of the graduations for anger – disquiet, irritation, annoyance, anger, rage – and in consequence, tend to only recognize when they are angry or enraged. Learning to tune in to, accept, and express or understand less intense feelings when they first occur can help prevent these from escalating and becoming troublesome to the person and/or to their relationships. Following is an exercise that focuses on feelings that may be difficult to express. Activity 10.12 Difficult Feelings Materials Two sheets of paper, and a set of crayons, or colored pencils, or felt markers for each group member. Procedure 1

2

3 4

5

Distribute the materials, and introduce the exercise by telling group members that there are some feelings that are easy for them to express, and some that are difficult. Instruct them to use the first sheet of paper and draw symbols for feelings that they find easy to express. Ask them to use one color for each symbol they draw. The symbols can be representative, abstractions, or just splashes of color. Whatever they choose to do is acceptable. Instruct them to take the other sheet of paper and repeat step 2 for feelings they find difficult to express. Have each group member show the drawings for feelings that are easy to express. After which, each will show the symbols for feelings that are difficult to express. The group leader should note similarities among symbols and colors chosen. Lead a discussion on what members find difficult to express, and how facilitation of these can be accomplished in the group.

Managing Difficult Member Behaviors Difficult member behaviors include monopolizing, story-telling, prolonged silence, the help rejecting complainer, and scapegoating. There are leader strategies to address these behaviors, such as redirecting, linking, and the like; but there can also be group activities that can be effective interventions. Examples of creative activities for three of these behaviors are presented.

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Monopolizing Attention can be the goal for the monopolizer. While group members can be grateful in the beginning of the group to have a person who keeps the session moving, it is not long before this behavior become tiresome and annoying. Leaders can use strategies such as blocking and redirecting as interventions, but there are times when these strategies may not fully address the behavior, or do not work. A creative activity such as the following may be helpful. Activity 10.13 Gifts Materials 5”  8” lined index cards, and a pen or pencil for writing. A suitable surface for writing would be helpful. Procedure 1 2 3 4 5

Distribute the materials and introduce the activity by telling members that each brings unique gifts to the group. Ask them to list each member by name, and to identify one or more gifts that person brings to the group, such as willingness to share important feelings. Allow sufficient time for writing, and then ask members to read the lists aloud. Ask members to report on how they feel about the gifts that were identified about them. Explore the feelings and reactions that members had while doing the exercise, and while receiving the feedback.

Story-Telling Many group members will engage in story-telling because they want others to fully understand their situation. However, it is seldom necessary to have all of the details, and although other group members will ask questions as a way of showing interest or to keep that person talking so that they don’t have to talk, the group leader should intervene as valuable group time is being consumed in providing details that do not contribute to understanding or growth. An activity such as the following can be an effective way to block the story-telling, and to engage all group members. Activity 10.14 My Story Materials Sheets of paper for drawing, a set of crayons, colored pencils, or felt markers for each person; and a suitable surface for drawing.

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Procedure 1 2

3

4 5

Distribute the materials and ask members to close their eyes. Next, ask members to think about a personal story they would like to tell the group, or think it would be important to share, and to let the story come to mind and unfold. Tell them that when they are ready, to open their eyes and draw a picture that captures the essence of their feelings about their story. Not the story itself, the feelings about it. The picture may be realistic or abstract. Allow sufficient time for drawing. When members seem finished, reconvene the circle and have them share their drawings. Explore what was learned about each member’s story from the feelings picture.

Scapegoating Group leaders have to take immediate steps to intervene when a member is becoming an identified patient, or is scapegoated. While the identified patient is receiving attention and is being listened to, that member is also in the position of being placed on the hot seat with too much attention that produces discomfort. Further, by having an identified patient, other group members are not working on their personal issues and concerns, but are putting their energies toward fixing the identified patient. The scapegoated member can easily feel excluded as they become the repository for other group members’ negative feelings, and have to carry these unless there is an intervention that helps group members acknowledge and express their own negative uncomfortable feelings. Scapegoating can also be a disguised and displaced attack such as what can happen when the group is fearful of or reluctant to challenge the leader, and directs the challenge to a group member. The leader has to intervene in a way that protects all group members without placing any group member in a scapegoat position. Activity 10.15 My Current Feelings Materials Sheet of paper, and a set of crayons, or colored pencils, or felt markers, and a suitable surface for drawing. Procedure 1

Distribute materials and ask members to select colors and draw shapes for the feelings they are experiencing in the here and now. Tell them that they may be experiencing several feelings, some are major and some are

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3

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minor and to draw these in proportion – that is, the minor feelings would be smaller than the major ones. Tell them to select the color that best depicts the particular feeling. Allow time for drawing, and reconvene the circle and have members share their drawings with a focus on what the feelings are, not on why they have the feeling that they do. Discourage exploration of why that particular feeling. Notice if the majority of the feelings depicted are positive or negative, and how difficult or easy it is for them to express these feelings.

Summary This chapter presented fifteen activities that can be adapted and used for groups focusing on a particular condition held in common by all group members. The activities provide a means for the group members to express their thoughts, ideas, and feelings about their condition, to help them develop reasonable goals and expectations for progress and/or recovery, and to enable them to develop personal coping strategies.

References Brown, N. (2005). Psychoeducational groups. In S.A. Wheelan (Ed.), The handbook of group research and practice. (pp. 511–530). Thousand Oaks, CA: Sage. Bultz, B., Speca, M., Brasker, P., Geggie, P., & Page, S. (2000). A randomized controlled trial of a brief psychoeducational support group for partners of early stage breast cancer patients. Psycho-Oncology, 9(4), 303–313. Cuijpers, P. & Stam, H. (2000). Burnout among relatives of psychiatric patients attending psychoeducational support groups. Psychiatric Services, 51(3), 375–379. http s://doi.org/10.1176/appi.ps.51.3.375. Dyck, E., M. Hendryx, R. Short, W. Voss, & W. McFarlane (2002). Service use among patients with schizophrenia in psychoeducational multi-family group treatment. Psychiatric Service, 53(6), 749–454. Fristad, M., J. Ackerman, & E. Nick (2018) Adaptation of Multi-Family Psychoeducational Psychotherapy (MF-PEP) for Adolescents with Mood Disorders: Preliminary Findings, Evidence-Based Practice in Child and Adolescent Mental Health, 3(4), 252–262, doi:10.1080/23794925.2018.1509031. Goldstein, L., W. Mehling, T. Metzler (2018). Veterans group exercise: A randomized pilot trial of an integrative exercise program for veterans with posttraumatic stress. Journal of Affective Disorders, 235, 348–356. Herbert, R., I. Levesque, J. Vezina, J. Lavoiek, F. Ducharme, C. Gendron, et al. (2003). Efficacy of a psychoeducative group program for caregivers of demented persons living at home: A randomized controlled trial. Journal of Gerontology, 58(1), S58–S67. Landry-Dattée, N., A. Gauvain-Piquard, & M. Cosset-Delaigue (2000). A support group for children with one parent with cancer: Report on 4-year experience of a talking group. Bulletin of Cancer, 87(4), 355–362.

224 Creative Activities for Diverse Conditions McFarlane, W. (2002). Multifamily groups in the treatment of severe psychiatric disorders. New York: Guilford Press. McFarlane, P., & S. Saunders (2000). Educational support groups for male caregivers of individuals with Alzheimer’s disease. American Journal of Alzheimer’s Disease, 15(6), 367–373. Sen, E., A. Hocaoglu, & O. Berk (2019). Group psychotherapy with fibromyalgia patients: A systematic review. Archives of Rheumatology. ncbi.mlm.nih.gov. Uehara, T. Y. Kawashima, M. Goto, S. Tasaki, & T. Someya (2001). Psychoeducation for the families of patients with eating disorders and changes in expressed emotion: A preliminary study. Comprehensive Psychiatry, 42(2), 132–138. Vallina-Fernandez, O., S. Lemos-Giraldez, V. Roder, & A. Gutierrez-Perez (2001). Controlled study of an integrated psychological intervention in schizophrenia. European Journal of Psychiatry, 15(3), 167–179.

Chapter 11

Applications for Fostering Group Dynamics

Introduction This final chapter focuses on applications for using creative activities to foster group dynamics, prevent some group level problems, and to manage some group level difficulties. The major topics presented are considerations for planning and using creative activities, the use of activities to promote emergence of group therapeutic factors, to address some group difficulties, how activities can enhance manualized group therapy, and considerations for adapting creative activities for children, adolescents, adults, and older adults.

Planning Creative Activities for Children’s Groups Critical components when planning for children’s groups are their ages, educational level, and the purpose for the group. Group leaders should be prepared to fully describe orally and in writing what is planned for the group, and to present this to both the children and their parents. If this is taking place in a school setting, the leader should also be prepared to describe this to the administration. This is especially important for obtaining informed consent, which you must have before the group begins. The critical elements noted previously are the ones that play the major roles for determining group membership. Try to limit the range of ages, and educational level, and not to mix too many different ones. That will make it easier to plan activities that maintain interest and attention. Other organizing elements include planning for briefer sessions, selecting instructional strategies and activities that take into account members’ attention spans, using more active experiences, building groups and/or sessions around themes, and limiting information. Plan briefer sessions for children up to ages 10 or 11, than you would for older children. They work better with 20- to 30-minute sessions, although some may be able to tolerate 50- to 60-minute sessions. Because sessions are brief, this means that the leader must plan extensively, and has to be as DOI: 10.4324/9781003251989-11

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emotionally present as possible. This ensures that order is kept, behavior does not get out of control, inappropriate comments and behaviors are blocked, members retain their focus, and that emotional expression is fostered. The attention span for all children is shorter than that of adults, and you will need to make many accommodations for keeping their attention. It is much better to plan for this than to have to adjust within a session, or after the group begins. You may not be able to rely on verbal input or interactions to keep their attention, or to help the session progress. It can be helpful to use active group experiences that call for every member to participate. It is also important not to have too many activities in order to give members some time to integrate the learning and understanding that the activity is intended to accomplish and to allow for self-reflection. It is a balancing act that is dependent on the leader’s expertise. Theme-related groups and sessions can bring needed structure, focus, and emphasis because activities, information, and even instructional strategies have a cohesive direction and purpose. Themes such as emotional expression, grief and loss, managing difficult emotions, self-perception, communication skills, relational skills, and so on, are examples for an organizing theme-related structure for a group. Limiting information applies to groups of all ages, but it is essential for children’s groups. Provide essential information and do so in several forms because repetition can help with incorporation and use of the information. For example, it may not be sufficient to just lecture or orally present information. It could also be written in an outline with essential points, be the focus for an activity, and presented more than once. Children will be able to use information that is simple in its presentation, and when they are guided to understand what personal application it has for them. Other important considerations are the size of the group, parental or other approval, and the environmental factors such as seating and surfaces suitable for the activities. Most of the activities in this book can be adapted for use with children by reducing the number of steps or what is asked for in the activity to fit the time available for completing the activity and allowing every child to report. Some activities may be too complex or the group too large to adequately complete the activity. Before using an activity with children in a setting such as a school or residential facility, it may be necessary to get approvals. Be sure to check on the need for outside approval of an activity and be prepared to describe the activity and what the goal is for using it. Following is an illustration of how to adapt an activity for children. The activity illustrated is presented later in the chapter for use with adolescents and adults. The activity illustrates universality and can be used as an introduction with children. First will be the activity as it appears later, with highlighted parts used to illustrate the adaptation.

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Activity 11.1 Similarities Materials Paper, and a set of crayons, or colored pencils, or felt markers, and a suitable surface for drawing. Procedure 1

2 3

Distribute the materials and ask members to draw a symbol or something to depict each of the following: a value, a cherished material object, and a favorite activity. The value, object and activity should be something that they think would make them connect to another group member if it were held in common. For example, if another member also read mysteries, the person would feel connected to that member. After drawing, reconvene in the group circle and report on the drawings. The leader should point out similarities among the drawings. Ask members if they identified any other similarities as they listened to each present their drawing.

The adaptation for item 1 would be to have a different set of activities for children such as a favorite game, television show, playtime activity, food, or place. Instead of asking them to draw symbols, ask them to draw something to represent their item such as something that represents their favorite game. Item 2 would need to be handled carefully as it is possible that group members will want to go into more detail or tell stories or talk more, which will reduce the time needed for the other group members to report. It may be best for the group leader to be ready to stop a group member in order to have time for all to report. Asking members if they see other similarities among them can help focus the children on similarities rather than differences.

Planning for Adolescent Groups Leaders of adolescent groups should first know and understand general growth and development issues for that age group. It is easier to understand adolescents when you know what is usual and expected so that you can more easily identify what is unusual and unexpected. Some basic considerations for leading adolescent groups include length of sessions, fostering therapeutic factors, containing and managing intense emotions, the need for structuring and directing, and encouraging them to seek other sources of information. Leaders will also need to have and display patience and empathy as adolescents are encountering the tumultuousness of growth and development present for all adolescents with the addition of their condition or disease. Building creativity and inspiration can also be of assistance.

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Length of sessions can be longer for adolescents than for children although it may still be wise to limit sessions to no more than one hour. Their attention spans are longer, but you run the risk of further intensifying emotions that are already intense, and/or leaving them with emotions they will be unable to adequately control outside the sessions. As with children, you will also want to limit the range of ages in a particular group. Girls will tend to be more mature than boys of the same age, and this too may be a consideration when forming a group. It may be helpful to have an age span of two to three years only for a group. Any more than three years may lead to difficulty. Fostering therapeutic factors, especially hope, altruism, universality, and existential issues can be very helpful. While these factors are helpful for everyone, they may be especially helpful for adolescents who are searching for a selfidentity, trying to gain independence while still in a very dependent state, and are trying to form meaningful connections. They need direct expressions and examples of hope, opportunities to be altruistic, the connections that are forged from commonalities, and opportunities to reduce loneliness, isolation, and alienation. Leaders may need to introduce these topics and/or use exercises that allow these factors to be explored. Containing and managing intense emotions for almost all adolescents are leader tasks that should be expected. Adolescence is a time of fluctuating moods and emotions at the best of times. When a condition or illness is encountered in addition, it’s no wonder that these adolescents can be constantly in the grip of intense emotions. The leader’s skill at containing and managing these provides relief for a short period so that they can explore issues and concerns in the session, teaches them that emotions can be managed, and provides modeling of how that is accomplished. There is a considerable need for structure and direction to help adolescents know what the limits are, to let them understand that safety is recognized as important, to emphasize the group’s purpose and goals, and to give support for helping to contain and manage anxiety. These psychoeducational groups are brief, and much needs to be done in a relatively short time. Add to this the intense anxiety of the age and condition of members, and it is easy to understand that more will get done if there is sufficient structure and direction. It may even be advisable to have a set of procedures for each session, and to stick to this as much as possible. For example, each session would have information presenting, such as a lecture or video, discussion, an exercise, and so on. The leader would be flexible enough to adapt to unexpected crises, and other important needs, but there would be a set procedure for each session. However you choose to have structure and direction is your decision. Encourage members to seek other sources of information. Sources such as books, self-help tapes and books, videos or DVD, the internet, and even others who have experienced the same condition or illness can be of assistance. You cannot provide all the available information, nor can you tailor for each member as there is not enough time, nor can you know enough about each

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member prior to the group to meet their needs. When members seek other sources of information, they are active participants in their own progress and development, and this can be empowering. Following is an activity for adolescents that can help focus on similarities. Activity 11.2 My Favorite Things Purpose Self-identification. Materials A sheet of paper and a pen or pencil for writing, a suitable writing surface. The group leader should prepare the list to post in advance of the group session so that group members will know what they are asked to do. The leader should also prepare another list to show with their answers to the items. Procedure 1

2 3 4 5

6

Prepare a list with the following: list your favorite color, food, music, television show, weather, book or reading material, music, sport or recreation activity, and vacation spot. Introduce the activity by showing the leader’s items on the list. Then, show the page with the list of items on it. Tell the participants to make a list of their answers for the items on the list such as their favorite sport. Reconvene the group and ask members to read their lists while the leader notes similarities. Next, ask participants to talk about creating their lists and which items could be easily named, those that took some thought, and if there were any that they did not list. Finally have group members write a summary statement about how they feel about their “favorite things”.

Planning Groups for Adults and Older Adults Planning groups for adults is much less complicated than planning groups for children and adolescents in many ways. Their attention spans are usually longer, they usually have the cognitive skills and techniques to absorb a larger amount of information, there can be fewer behavior problems, they have more experiences and resources to share with each other, and can be more self-reflective. On the other hand, they can be more resistant to make needed changes, exhibit more hopelessness and helplessness, and some members will

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not like the idea of needing or accepting help for fear of appearing weak or inadequate. In addition to the previous general guidelines, significant factors for adult groups can be cognitive abilities and educational level, gender, past traumas, and current support system. Adults, like children and adolescents, will have differing cognitive abilities. It can be helpful for leaders to know and stay aware of possible effects on members’ participation as cognitive ability can significantly impact learning, understanding, and interactions in the group. For example, the person who is taking pain medication may be influenced by the sedating effects making it difficult for them to focus, take in and process information, or to actively participate. The group member may not even be aware of their impairment as it can be subtle. Persons with very limited cognitive ability may not benefit when placed in a group with higher functioning members, and vice versa. Educational level is an important consideration for adult groups because it plays a role in the leader’s decisions about what information to present, instructional strategies, and the amount of information that can be absorbed and learned. Then, too, there can be members’ apprehensions about being included or excluded because of having little or by having considerable education. Mixing a wide range of educational levels can sometimes produce a rich experience, but sometimes it can make for a difficult and uncomfortable group experience because of members’ fears, defensiveness, or arrogance. Your planning can help mediate these effects. Gender is a factor that can produce considerable projection, transference, apprehension, and possible eroticism in groups. Members’ previous experiences with members of the same or opposite sex, sexual orientation, impulsivity, expectations for behaviors and attitudes are some of the aspects related to gender. You cannot prevent any of these effects, but you can anticipate them, recognize them when they appear, and understand their influences. Past traumas play a significant role for everyone in all types of groups. If group leaders are able to screen members prior to group experience, they may be able to recognize when members’ reactions, interactions, and/or responses are more related to past trauma than they are to current experience and/or their condition or illness. Central to fostering hope and recovery is the extent of a member’s support system. Although this factor is outside the group, it can be helpful for members to become aware of the strengths and weaknesses of their support system, to begin to develop and/or strengthen it, and to capitalize on this resource. Your planning can include what you can do to highlight this factor; help members learn and practice behaviors to strengthen, develop, and maintain meaningful relationships both in and out of group; and how the group can be developed to serve this function in the short term. It is very important that group leaders pay attention to the physical and mental capabilities of their adult group members and the need to adapt or adjust their activities to meet the physical and mental needs of group members

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and this may be especially important when working with older adults as well as with impaired adults. Suggestions for adaptations include reducing the task, using suitable materials, and selecting activities to meet the members’ and the group’s needs.

Creative Activities for Group Level Concerns It would be the rare group leader who has not encountered one or more group dilemmas where the group became mired, tense, unproductive, little therapeutic work was accomplished, and this lasted more than one session. While frustrating for the group leader, these situations can be even more frustrating for group members who probably lack the developed inner resources for coping that the leader may have leading to a very uncomfortable group situation for all. Adding to the frustration for the group leader is when all interventions tried do not move the group from the uncomfortable place. The leader’s analysis does not seem to be effective to produce understanding, or for suggested interventions, no matter how experienced or competent the leader is. While these group situations are few and far between, they can occur without warning. These group dilemmas differ from those presented by a difficult group member. Brown (2006) and Alonso and Rutan (1993, 1996) describe some group dilemmas that can result from the presence of members with unidentified problems and concerns such as, the member with a Narcissistic Personality Disorder or with a Destructive Narcissistic Pattern, a member with a Borderline condition, or a quiet explosive member. They propose that the difficulties and dilemmas in these instances, result from the group’s effort to manage and contain these members, the members’ unconscious sensing of danger and possible destruction for their selves, and their attempts to control their intense emotions that were unconsciously aroused by these members. The leader and members are working in the dark, but nothing constructive can happen until the difficult member is identified and appropriate actions are taken. These difficult group members present their own variations for group dilemmas, but this is not what is meant for this book. Suffice it to say that group leaders encountering these dilemmas look for ways to understand the indirect communication so as to select appropriate interventions. The group members do not have the ability to be clearer in communication because they don’t know what it is they want to communicate, can be fearful of consequences for what may emerge, are trying to understand and communicate but are ineffective, and are frustrated at the lack of clarity and understanding from self, other members, and the leader. Proposed is that the described creative activities can assist the group leader to address some group dilemmas and provide relevant material for group members’ self-exploration. These activities, although group centered and focused, can be personal for each member, bypass defenses, reveal

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unconscious and hidden material in ways that can be perceived by them as less threatening and dangerous, encouraging for expression of difficult and/or complex ideas, thoughts and feelings, and even may provide guidance to solutions for some members. At the very least, these creative activities can provide a release of tension so that group members can think clearer, be more responsive, and be more willing to engage in self-exploration. Both the group and members can benefit. Described are activities to promote the emergence of group therapeutic factors, and to address resistance and conflict. Activity 11.3 Resistance Artist Trading Card (ATC) Materials Refer to the materials lists under the section on guidelines (Chapter 2). Procedure Find a suitable place for the group to work where there are tables or the like to display the materials, and create the collages. 1 2

3 4 5

Introduce the activity by explaining what ATCs are and showing some examples of these. Ask group members to reflect on resistance and what it feels like, especially in group sessions. Tell them that the resistance could be their own personal resistance, or when they feel others’ resistance. Spread the materials out where they can be available to all group members. Give a time frame for constructing the collage. Allow members to work and observe if they talk among themselves, or tend to be silent, and other such behaviors. Follow the guidelines for calling time, reporting or sharing, and for exploration and enhancement.

Therapeutic Factors The importance of factors conducive to promoting therapeutic progress, healing and change for group members has received attention in the literature. (Corsini & Rosenberg, 1955; Kivlighan & Mulligan, 1988; Colijn et al., 1991; Kivlighan & Goldfine, 1991; Crouch et al., 1994; Fuhriman & Burlingame, 1994; Yalom, 1995; MacKenzie, 1990; Dies, 1997; Fuhriman, 1997; Kivlighan et al., 2000; MacNair-Semands & Lese, 2000; Kivlighan & Holmes, 2004; Tschusckke & Dies, 1994). What has emerged from these studies and reviews are confirmation of the impact of behaviors and attitudes that are clustered as categories for therapeutic, curative, and change; some are common and valued for all types of groups, some differ in their importance and value depending on the type of

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population; and that there are few guidelines for leaders on how to foster and encourage the emergence of these factors. These factors have been given various titles, but can be generally categorized as Yalom (1995) presented them. These eleven factors are: Universality – emphasizing commonalities among group members, reducing their feelings of alienation, of being alone in their struggles or misery, and/or that they are weird or significantly different from others in negative ways. Instillation of hope – providing motivation to continue the struggle and provides a feeling that the struggle will pay off in meaningful ways. Hope can increase members’ self-perceptions of worth and value to others and to the universe and is inspiring. Altruism has been shown to be beneficial for the giver and to the receiver. Altruism is giving freely of oneself without expecting a return and group members can realize that they do have something of value to give to others. It is also rewarding to receive from others especially when there are no expectations attached to the gift. Interpersonal learning – allows members to increase self-knowledge and selfunderstanding through feedback from others. This feedback provides the personal with information that others can see, but that is usually not seen by them, but could be important for relating and communicating with others as well as achieving a greater understanding of their thoughts and feelings. Guidance or imparting of information is not advice giving. Rather, this therapeutic factor decreases ignorance, empowers the receiver to act on their behalf, and increases the capacity to develop solutions for problems. Catharsis – is generally thought of as emotional venting. The therapeutic use of this in the group can bring relief for group members when suppressed or when repressed intense feelings are expressed and receiving responses that do not destroy oneself, others, or relationships. However, in order to be most effective, the emotional venting must be accompanied by a greater understanding of oneself through receiving empathic responding, differing perceptions or other feedback that promotes self-understanding. Corrective recapitulation of the primary family group – or reenactment of the family of origin makes a valuable contribution to therapy by providing a new perspective for old hurts, resentments, and relationships that can promote healing, forgiveness, and changes. Imitative behavior – is demonstrated by both the leader and members. Members can learn and practice new and more effective ways of behaving to get needs met, develop more constructive attitudes through seeing the modeling behavior of others that is more effective than their present behavior. Corrective Emotional Experience Existential factors – are usually present in all groups although these may not be visible or prominent. The therapeutic awareness and discussion for these

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factors are encouraging to members as these discussions promote awareness that these issues do not have solutions (e.g. the indifference and unfairness of the universe); that all human beings struggle with these issues throughout their lives; and that each person has a unique approach and resolution for these factors. Socializing techniques – are very useful for almost all group members. Teaching members these techniques demonstrates how they can initiate meaningful connections to others, reduce behavior and attitudes that prevent connections, and increases awareness of others-in-the-world as separate and distinct individuals. Cohesion – provides the necessary conditions for the productive or working stage of the group. This is therapeutic because the group has reached a point where members experience feelings of belonging, connectedness, and productivity; they have learned the benefits of cooperation versus individual efforts, and there are increased feelings of satisfaction with self and with others.

Foster the Emergence of Some Therapeutic Factors Presented next are three creative activities related to fostering the emergence of three factors in the group; universality, hope, and catharsis. Each has a short introduction to explain the importance of the particular factor that may also be useful as an introduction to the activity. Universality can be reassuring to members that they are not alone, isolated, or weird. The commonalities among group members promote disclosure, caring, and concern, and can lead to group cohesion. Thus, it is very important for a group leader to give some attention to this therapeutic factor and take every opportunity to highlight similarities among group members in attitudes, experiences, feelings, and so on. Doing so could help this therapeutic factor to emerge and be recognized. Activity 11.4 Similarities Materials Paper, and a set of crayons, or colored pencils, or felt markers, and a suitable surface for drawing. Procedure 1

Distribute the materials and ask members to draw a symbol or something to depict each of the following: a value, a cherished material object, and a favorite activity. The value, object, and activity should be something that they think would make them connect to another group member if it were

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held in common. For example, if another member also read mysteries, the person would feel connected to that member. After drawing, reconvene in the group circle and report on the drawings. The leader should point out similarities among the drawings. Ask members if they identified any other similarities as they listened to each present their drawing.

Encouraging hope can also be facilitative, and the group leader can assist in its emergence and being realistic. Unrealistic hope is a fantasy, and failure to achieve what was hoped for can be depressing and lead to self-defeating thoughts and feelings. However, it is hope that promotes persistence in the face of adversity and motivates change. Hope seems to be an individual perspective, and what is hopeful for one person may not be so for another. Further, it could be that some members are so focused on their misery, issues, problems, or concerns that they have not been able to see hope in their lives, nor do they have a clear idea of their personal signs of hope. A drawing activity that focuses on identifying signs in indices of hope would be very helpful. A further note, hope can grow among group members as they observe hopefulness in other members. Seeing others get better, resolve problems, make progress, and feel more secure and confident can serve as models for group members that they too can experience these. This is an example of hope that is realistic and reasonable. Activity 11.5 Hopefulness Materials Paper and a set of crayons, colored pencils, or felt markers. Procedure 1 2

3

Find a suitable surface for drawing and distribute the materials. Introduce the activity by telling members something similar to what was presented in the previous paragraphs and ask them to draw a symbol of what hopefulness would feel or be like for them right now. Reconvene in the group circle and share the drawings. Explore the meanings of hopefulness for members and discuss how some or all of this can be obtained in the group. The leader should be careful to note which are realistic, and which may be fantasy. For example, having another person change is fantasy. Learning to cope with what is, can be realistic.

Catharsis is another therapeutic factor, and the expression of feelings that were suppressed, repressed, or denied; or becoming aware of having difficult or

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unacceptable feelings can be of immense help to group members. This can be especially true when the emotional venting is met with reactions of understanding, care, and concern for the person instead of the feelings being soothed, rationalized, minimized, or criticized as being irrational or wrong by others in the group, such as what can happen in other settings like the family. However, catharsis is most helpful in the group when it is accompanied with the interpersonal learning described by Yalom (2021). The catharsis then is not just emotional venting, as the person can learn something unknown, or of which they were unaware, that is valuable for self-understanding and growth. The group leader facilitates the catharsis and the feedback that promotes the interpersonal learning. One way feedback can be encouraged is by asking group members to tell the member experiencing catharsis their personal feelings experienced while listening to them. A drawing activity could be used for each, expressing strong intense feelings, and reactions to the catharsis. Activity 11.6 Catharsis Materials Paper, and a set of crayons, or colored pencils, or felt markers. Procedure 1 2

Find a suitable drawing surface and distribute the materials. 2. Describe catharsis noting that it is more than just emotional venting. Ask members to draw a picture from their experiences that depict catharsis where they learned something about themselves in the feedback they received in the interaction. For example, something upsetting happened at work, the person brought it to the group, vented, and the feedback they received increased the person’s awareness that they are in a toxic situation where nothing they did or said would make a positive difference, and that continuing to let it be upsetting was hurting them not the other person, and nothing positive was being accomplished.

Existential Factors Activity 11.7 Human Suffering – An Existential Factor Materials Collage – magazine images, paper, glue or double-faced tape, cardstock and emphemera.

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Procedure 1

2

3 4

Introduce the activity by explaining what existential factors are as defined earlier in the chapter, and that they are universal and can only have current solutions and will emerge throughout their lives. Ask group members to reflect on their personal perceptions of human suffering and what it feels like or would feel like at the present time. Another way to present the topic would be to ask them to think about what would constitute or be illustrative of human suffering for them at the present time and to use the materials to make a collage that illustrates their thinking and feelings. Give the signal to begin the constructions and note how much time is allotted for the work. Follow item 4 in the previous activity, and the guidelines for reporting, and exploration.

Identifying unresolved family of origin issues and other unfinished business that members have can be very helpful to their progress but can also be difficult to accomplish. Drawing activities can contribute to the uncovering by each member at the same time. When either of these is the purpose or goal for using a drawing activity, the leader should be emotionally prepared for intense emotions, and/or for unexpected material to be uncovered. Further, the group should have sufficient safety and trust established so that members will be more secure when disclosing painful material, and not have to be overly concerned about the leader’s reactions to this material, feeling confidence that the leader’s response will be understanding, show caring and concern, and that other group members will not be rejecting. All of this suggests that the first stage of group, and groups that are focused on other than counseling or psychotherapy may not be appropriate for an activity that focuses on this factor. When a drawing activity is used to accomplish the goal or purpose of identifying family of origin factors or unfinished business, the group leader should do the following.








Ensure that all members have an opportunity to report their personal experiences. Gauge the emotional intensity aroused for each member. Resist deeper exploration for a member at this time, but note a need to return to it. Block critical and/or blaming comments by other group members. Give empathic responses to each member (this can be essential). Identify similarities in experiences and/or feelings among members. Reduce emotional intensity before the group ends so that group members do not leave with feelings that are overwhelming or difficult for them to manage. A check on emotional intensity, and a short relaxation activity can be helpful.

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Address member difficulties, e.g. transference, resistance, problem behaviors. Address group difficulties: conflict, resistance, defensiveness, tension. There are numerous group level challenges that can arise, and drawing can be a helpful strategy to bring these to the awareness of group members, and to suggest solutions. Group level challenges are issues and concerns that seem to be problematic for all group members even when they differ in intensity and kind for separate group members. For example, resistance and conflict are present in all groups, but in some groups these become barriers and constraints because members repress, suppress, and/or deny they exist. They tend to minimize or ignore them, fearing the loss of control, harmony, or even of destruction. However, these challenges continue to affect the effectiveness of the group. Use of a drawing activity can reduce some of the perceived threat of even being aware of these challenges. Examples of group level challenges include:







Fear of intimacy Resistance Suppression of important feelings Conflict Fear of being seen by others, and thus being shamed Loss of control

Following are activities to address resistance and conflict. Using activities such as these can make it easier for members to discuss these threatening concepts. Activity 11.8 Resistance Materials Suitable surface for drawing, 5”  8” index cards, a set of crayons, or colored pencils, or felt markers for each group member. Procedure 1

2 3 4

Distribute the materials and ask members to sit back, close their eyes, and think of the concept, resistance. Think about what resistance feels like, what it looks like, which can be symbolic or representational, and its other characteristics. Tell them to open their eyes and to draw what emerged as they thought about resistance. When the drawing is complete, ask members to share their drawings. Explore the feelings that emerged as the directions were given to think about resistance, when drawing the concept, and when sharing their drawings in the group.

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If appropriate and the group has developed sufficient safety and trust, the leader can have a discussion about members’ experience of resistance in the group with a focus on their personal resistance.

Activity.11.9 Conflict Materials Paper, and a set of crayons, colored pencils, or felt markers for each group member. Procedure 1

2

3 4

5

Distribute materials and ask group members to draw a picture that captures the essence of a personal conflict with another person or persons, either from the past or is current. When drawing seems complete (the leader may have to set a specific time frame for drawing), reconvene in the circle, and ask members to describe their drawing. As they describe their drawing ask them what feelings they are experiencing as they talk about their conflict. Ask each how they handled, or are handling the conflict. Note if they describe ignoring it, minimizing the impact on them or on others, suppressing the conflict, or even denying that there is a conflict or the seriousness of the conflict. Bring the discussion to what is happening in the group, and explore if members are handling conflicts in the group as they did with the one that they drew.

Creative Activities for Manualized Groups Manualized groups generally use a manual or curriculum designed and published based on the result of research about interventions for a particular issue, problem or concern. There are advantages and disadvantages for using these manuals, which can present challenges for the use of creative activities. First described are the advantages for using manuals for group therapy. Next is the descriptions for the disadvantages and finally, are some suggestions for how creative activities may be incorporated into the group therapy without compromising the treatment fidelity, which is based on following the manual. Advantages for Manualized Groups There are nine primary advantages for manualized groups: basis for the manual; sequencing of learning; pre-prepared session plans; the availability of

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preprepared presentations; evaluation and assessment forms and processes; forms and activities such as homework are provided; narrow goals and objectives; and planning time is reduced. Manualized group therapy can be instrumental in reducing group leaders’ anxiety about what and how to organize and direct the group sessions. The strategies and techniques for most manuals were developed from research findings for the particular issue, condition, or problem. This makes it easier for the group leader to be able to support the group treatment strategies and techniques as being evidence-based. The material that comprises the manual has a sequence for presenting the cognitive material as well as guides for effective ways to present the materials. Many manuals may have curriculum/ session plans that specify objectives with recommended strategies and the sequence for presenting these. The group leader is expected to follow these preprepared plans and is not left to develop these on their own. In addition, the plans follow the goals and objectives that provide the framework for the manualized treatment. Some manuals and ancillary material contain preprepared presentations that include media. This makes it easier for the group leader to prepare for the group as the most essential information is provided as well as the presentation method. It is also essential that the group leader be familiar with what is being presented as they will have to answer questions and lead discussions. Manualized therapy will many times also include evaluation forms as a part of the manual either as print material or on a website. Using these forms assists the group leader to assess members’ progression as well as assessing the efficacy of the group treatment. Another advantage for these forms is that they usually have evidence for validity and reliability. Manualized treatment is usually focused on narrow and specific goals and objectives. This narrow focus has goals that are usually behavioral in nature and are capable of being observed and assessed such as reduction in the number of days overeating. They are not vague such as “feeling better”, or subject to personal interpretations where each person can have a different interpretation or meaning. Some manuals will have activities and other forms, as well as specific homework for group members. There are helpful because the group leader will not have to find or create these and have the advantage that they have been designed for the specific topic that defines the group. It is important that the group leader use the forms, activities, and homework specified in the manual as these will be a part of the therapeutic fidelity to ensure that the evidence-based treatment will produce the desired results. The knowledge to be disseminated is included in the manual. Having this information already prepared can save the group leader considerable time and effort to seek out and prepare the relevant information. On the other hand, there can be new material that has emerged or created since the manual was developed and will not be included. This is why it is still important for group leaders of manualized groups to also do a literature search to determine

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whether there are updated findings that would be relevant prior to implementing the group. The use of manualized therapy not only reduces the time the leader needs for planning; this can also help to reduce some leaders’ anxiety about the ambiguity and uncertainty that can be present when planning, organizing, directing, and presenting group sessions. It can be comforting to group leaders, especially beginning group leaders and those who have not had enough training, to have to facilitate a manualized group. Disadvantages for Manualized Groups However, there are some constraints to facilitation for manualized groups: strict adherence to the manual, group leadership skills and processes to be used, and the limited use for creative activities. The studies on the use of manualized groups emphasize the need for strict adherence to the manual in order for treatment to be most effective. While minor modifications can be made, such as to accommodate members’ reading abilities, major deviations can affect the outcomes and, in some instances, may invalidate the results. Group leadership skills and processes may not be included such as empathic failures and their repair so that, unless the group leader is already educated about these, the group facilitation may be affected. Also, for manualized groups, there is little attention given for the constructive use of group dynamics, stages of group development, therapeutic group factors, and strategies for managing difficult group member behaviors, nor do they provide for an understanding of group process or use of group process commentary when facilitating group therapy. The final disadvantage that is presented relates to the absence of guides for the leader to manage group member factors such as managing and containing intense emotions, and member to member interactions. Some of the richness of group leadership is reduced or eliminated. Enhancing Manualized Groups with Creative Activities The success of manualized group sessions depends on the group leader’s knowledge and group facilitation skills as well as adherence to the manual. There may be some minor adjustments that need to be used but the manuals provide the structure and frame for the sessions and the group leader must be aware of what adjustments can be made within the framework of the manual. Creative activities can be used in manualized groups and following are some suggestions for how they may be incorporated in the very structured and directed session: embedding, metaphors and symbols, reducing, and connecting.


Embedding refers to incorporating a short activity as part of the presentation of didactic material. For example, group members can be asked to list their thoughts and feelings about specific points that are being

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presented and then allow time for them to read these at the end of the presentation. The requests for lists can even be presented as part of a PowerPoint presentation. Determine if there are metaphors in the materials and/or in members disclosures and ask them to present these by drawing symbols for them. Distribute materials and ask members to draw or use colors for the feelings and thoughts that are triggered by the group, or a presentation. Use short periods of mindfulness or meditation to reduce intensity of distressing feelings, everyday stress, triggers for the behaviors that are the focus for the therapy, and to bring members into the here and now. Highlight members’ connections shown through their products and in their reporting. Short drawing and writing creative activities can be used to expand and reinforce the learning presented by the material. Use stress reduction techniques such as progressive relaxation, meditation or breathing. This can help reduce members’ tensions thus promoting more active involvement especially with personally sensitive material.

There are many opportunities for group leaders to include creative activities in their manualized groups. Group Dilemmas Cases and Creative Activities Following are four vignettes that describe some possible group situations, all with adult group members. Read each and imagine that you are the group leader and are encountering the situation. Try to put yourself in the group, accept that you tried interventions, but these were not successful, and that the group continued this unproductive behavior. What would you do then? Some suggested creative activities interventions follow each example. Case Vignette I A was the group leader of a group for young adults ages 29 to 36. This group had been meeting once a week for the past three months and was becoming more cohesive where members were beginning to engage in important self-disclosures. Sessions were interesting and lively. A encouraged interactions among members, and they responded well. Everyone seemed satisfied and willing to participate, attendance was regular, and members came to sessions prepared to work. During the twelfth session, about midway through the number of scheduled sessions, an active group member announced that they needed to leave the group to care for a parent in another city who was recovering from a stroke. A had met with the leaving group member in advance of this session to plan the announcement and how to manage their feelings around leaving the group.

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After the announcement, group members expressed their shock, dismay, and feelings of loss. A had anticipated this reaction and guided the session so that the leaving group member and other group members could express their feelings and take care of any unfinished business that might be present. The next session continued the goodbye and grieving process for the group members, and several of them expressed regrets that A was no longer a part of the group. A had also anticipated this possible reaction, and did not push the group to move on, feeling that they would do so when they were ready. Some personal concerns surfaced, but members seemed disinclined to deal with them, as these were quickly dropped when getting little response. The group leader became concerned when the pattern of surfacing personal concerns and then dropping them continued for the next two sessions. A tried to respond to the concerns, but the members who spoke of their concerns would not or did not pursue the leads or guidance. Members rarely spoke, and seldom was there any interaction among members, except at the beginning of the sessions where they did talk about the weather, traffic, sports, and other such topics. Sessions lacked energy, nothing A did encouraged participation, and little or no therapeutic work was being done. A tried to analyze what was taking place in the group and considered whether or not the group was continuing the grieving process, had fears of intense uncontrollable emotions surfacing in the group, that members wanted to challenge the leader but were fearful of doing so, and/or that something important that the group needed was being overlooked. A tried introducing each of these, but the group remained unresponsive, denying the possible fears, and stating that they felt safe enough to express their feelings, or to challenge the leader. Let’s assume that these are well-functioning adults without disabilities. The leader may want to consider using a movement activity to energize the group; or a drawing activity to label and express current feelings; or an imagery activity where members image the group as a whole. Case Vignette II M was dreading the upcoming meeting for the group but was unable to pinpoint the source or reason for the feeling. M had just finally admitted that the dread and reluctance had been present for the last two sessions, and that there had been some disquieting thoughts and feelings about the group prior to those sessions. M reviewed the session notes, and the information about group members, but nothing jumped out as a possible reason for the dread. M did not feel this way about their other groups, and usually looked forward to group sessions. The dreaded session began for the group of eight young adults ages 25 to 35. They were attending the 12-session group because of relationship problems that they wanted to resolve, and this was the eighth session. The members were all working in productive jobs, reported that they were in reasonably good physical health, did not have any major past traumas such as abuse or rape, and seemed to be genuinely interested in what the group could offer them. Two members were divorced, three were in the process of separation for divorce, and three had never been married. M started this eighth session in the usual way by asking if there was any unfinished business from the previous session, there was none, and if anyone had something urgent and

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important to bring to the group, again there was nothing. The group sat in silence for a few minutes, which began to feel like an eternity to M. Just as M was going to intervene, a member started talking about their marital problems, and did so for most of the session. Whenever they sounded like they would stop, another member would ask a question, which then led to an extended answer. Finally, the session ended. As M wrote the session notes, a pattern had emerged over the last three sessions. It had gradually emerged, so that it would have been hard to detect earlier, but this last session really highlighted the pattern. M realized that the group allowed and encouraged story-telling by one or two people, and that M’s efforts to stop it and get them more focused was ignored. The group seemed to agree that they needed to focus, but would almost immediately return to telling the story. There were also some long silences that members seemed content to endure, although someone always broke the silence. The stories were always a rehash of what the member had told before, there had been no movement that suggested progress or resolution, and other members just listened and probed for more details when they spoke at all. M realized that what was dreaded was more of the same, and at being unable or ineffective to stop this pattern of behavior. Creative activities could include using the next three sessions to have members write for 10–15 minutes about their thoughts, feelings, and ideas about the group, but not to read these or share in any way. Just to write. Another creative activity could be to have members construct ATCs on the topics of safety and trust in relationships, and to display and report on these in the group. A third alternative could be to use a short mindfulness meditation period, and afterward report on the perceptions and feelings experienced. Case Vignette III The group had started off with much promise and D, the group leader, was pleased with the progress so far. D felt that members were gaining benefits from the group that would encourage them to stick to their plans to combat their abuse of alcohol. D wasn’t naive with unrealistic expectations, having worked with many clients having this condition over the years and knew that their challenges would not be easily overcome, and that there was much hard work for them to do. But, D was encouraged because of the behaviors in the group, and members’ reported behaviors outside the group that seemed to be verified by family members. During the sixth session, D noticed that several topics introduced by members did not seem finished. As soon as one member finished talking, a perfunctory response was provided by another member, but then that member or another one, went on to talk about something else. D made a mental note to pay attention to this behavior and to bring it to the group’s attention if it happened again. The next session was a repeat of the previous one, and D did intervene with a group process comment. The members reflected on what they were doing, and possible reasons, but it was not long before they were back into the skittering pattern. The same happened the next session where D tried another group process comment. Members tried to be reflective about what they were doing but continued the established pattern. There was no new material in what the members were talking about, and they really seemed to try to cooperate with D’s interventions.

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Suggested interventions using creative activities include using drawing and collage with a focus on accessing and expressing feelings. The group leader may want to reflect on identifying the feelings that the majority or all group members find difficult to express, such as appreciation, happiness, anger, and fear. Case Vignette IV A conflict broke out between two group members when one accused the other of being bigoted, and the accused member responded that their religion was not bigoted and that the accuser was “just plain wrong”. The group leader, J, could tell that this topic was of immense importance for these two members as their nonverbal language seemed to signal “fight”. J tried to defuse the situation and lower the intensity by intervening and using some conflict resolution skills that usually worked. However, while the conflicted group members participated in the resolution process, neither budged from their initial position, and the group atmosphere remained very tense. When J asked other group members how they were experiencing the conflict in the group, the other group members reported that they had high levels of discomfort. A couple of members just wanted to agree to disagree and move on to something else, and several members reported that they wanted to leave and get away from the conflict. J felt that if the emotional intensity was not reduced that there was a real possibility that one or more members might not return to the next session. J decided to explore members’ feelings and reactions around conflict in general, not just the current one in the group, as an opportunity for both the members in the conflict and other group members to gain insight, and to possibly reduce tension in the group. All group members expressed many fears around conflict because they perceived it as destructive, that any conflict triggered fears of danger related to their childhood experiences, and most group members did not have expectations for positive outcomes from the conflict that was currently in the group. There were even some comments made that suggested a lack of confidence in J’s ability to moderate the conflict and fear that the group would be destroyed. The more members talked, the more intense the atmosphere became on top of the already heightened intensity. The conflicting group members said that they wanted to group to remain intact, and would just let the conflict go, and not try to resolve it. J knew that it was very unlikely that the group would be helped if the conflict was suppressed, as then the conflict would become the elephant in the room and would continue to negatively impact the group. The group leader has to intervene quickly and take charge of the group. Members are very fearful and some may even be panicking, and if not addressed this could effectively destroy the group. The group leader has the following tasks to perform, and these are in priority order:



Reduce emotional intensity so that members can leave the session able to handle their difficult feelings Reduce fears that the group and/or individual members are in danger of being destroyed

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Increase feelings of trust and safety in the group, and in the competence of the group leader to protect them from destruction or becoming abandoned Demonstrate that there can be a constructive resolution of conflict

Suggested interventions can begin with a breathing activity as described next. Activity 11.10 Reduce Emotional Intensity Materials None Procedure 1

2

3

4

The leader asks members to rate their emotional intensity at the present time using a scale of 0 – little or no intensity, to 10 – considerable or extreme intensity. Introduce the exercise by telling members that one way to reduce emotional intensity and to become calmer is to do a breathing exercise, and that you will lead them through this. Ask them to close their eyes, sit in silence for a moment, scan their body and note the tense areas such as their shoulders, and to become aware of their breathing pattern. Ask if they are breathing fast, slow, almost panting, or however their breath seems to them. Tell them that once they are aware of their breathing pattern, to try and consciously make it deep and even. They may not succeed at first, but to keep trying to breathe deeply and evenly.

Allow at least five minutes for breathing. 5

At the end of the allotted period, ask members to open their eyes and once more, to rate their emotional intensity. If the emotional intensity is five or higher, continue the breathing exercise until all members have less than a five rating. Another activity that could be helpful is the relaxation in movement. An imagery exercise where the members image taking a walk can also reduce intensity. It is essential that the emotional intensity be reduced before trying to address any of the other possible concerns.

Summary The final chapter focused on using creative activities to foster the emergence of group therapeutic factors, to address some group level problems and to manage some group dynamics. Ten activities were described.

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References Alonso, A., & Rutan, J. S. (1993). Character change in group therapy. International Journal of Group Psychotherapy, 43, 439–451. Alonso, A., & Rutan, J. S. (1996). Separation and individuation in the group leader. International Journal of Group Psychotherapy, 46, 149–162. Brown, N. (2006). Reconceptualizing difficult groups and difficult members. Journal of Contemporary Psychotherapy, 36(3), 145–150. Colijn, S., Hoencamp, E., Snijders, H., Van Der Spek, M., & Duivenvoorden, H. (1991). A comparison of curative factors in different types of group psychotherapy. International Journal of Group Psychotherapy, 41, 365–378. Corsini, T., & Rosenberg, B. (1955). Mechanisms of group psychotherapy: Process and dynamics. Journal of Abnormal and Social Psychology, 51, 406–411. Crouch, E., Block, S., & Wanlass, J. (1994). Therapeutic factors: Interpersonal and interpersonal mechanisms. In A. Fuhriman & G. Burlingame (Eds.). Handbook of group psychotherapy: An empirical and clinical synthesis. New York: Wiley. Dies, R. R. (1997). Comments on issues raised by Slavson, Durkin, and Scheidlinger. International Journal of Group Psychotherapy, 47. Fuhriman, A. (1997). Comments on issues raised by Slavson, Durkin, and Scheidlinger. International Journal of Group Psychotherapy, 47, 169–174. Fuhriman, A., & Burlingame, G. (Eds.) (1994). Handbook of group psychotherapy: An empirical and clinical synthesis. New York: Wiley. Kivlighan, D. Jr., & Mulligan (1988). Participant’s perception of therapeutic factors in group counseling. The role of interpersonal style and stage of group development. Small Group Behavior, 19, 452–468. Kivlighan, D. Jr., Coleman, M., & Anderson, D. (2000). Process, outcome and methodology in group counseling research. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (3rd ed., pp. 767–796). New York: Wiley. Kivlighan, D. Jr., & Goldfine, D. C. (1991). Endorsement of therapeutic factors as a function of group development and participant interpersonal attitudes. Journal of Counseling Psychology, 38, 150–158. Kivlighan, D. Jr., & Holmes, S. (2004). The importance of therapeutic factors. In J. DeLucia-Waack, D. Gerrity, C. Kalodner, & M. Rina, (Eds.). Handbook of group counseling and psychotherapy. Thousand Oaks, CA: Sage. MacKenzie, K. (1990). Introduction to time-limited group therapy. Washington, DC: American Psychiatric Press. MacNair-Semands, R. R., & Lese, K. P. (2000) Interpersonal problems and the perception of therapeutic factors in group therapy. Small Group Research, 31, 158–174. Tschusckke, V., & Dies, R. (1994). Intensive analysis of therapeutic factors and outcome in long-term inpatient groups. International Journal of Group Psychotherapy, 44, 185–208. Yalom, I. (1995). The theory and practice of group psychotherapy. (4th ed.). New York: Basic Books. Yalom, I., & Leszcz. M. (2021). The theory and practice of group psychotherapy (5th ed.). New York: Basic. Books.

Index

acceptance 23 active participation, in experiential learning 6 adolescent groups 227–229 adults groups 229–231 Agazarian, Y. 47 Aimone, K. 82 Alonso, A. 5, 231 altruism 233 anxiety, reducing 141 appropriate questioning 51 art-based activities 8; choice of 190–191; see also collage activities; drawing activities artist trading card (ATC) 232 assumptions guide, creative activities 23–25 attention 59, 221; adolescent 228; adults/older adults 229; children 226; receiving 179, 222 attributes, group leaders 44–46 auditory distraction 144, 181–182 authority figures 58 autobiography 98–100 awareness: focusing by drawing activities 70–71; immediate 70–72 Babani, A. 154 Band, J. 155 Barnes, S. 150 Bates, A. 150 Beck, J. 7 beginning stage, of group development 54–55 behavioral therapy 7 Bergman, A. 7 Bettelheim, B. 9, 161, 162, 164 Biegel, G. 151

Bion, W. 53 blocking 50–51 Bodin, A. M. 47 Borderline Personality Disorder 151 Brown, J. 174 Brown, K. 150 Brown, N. 5, 46, 51, 164, 206, 231 Brown, N. W. 16 Brun, B. 164 Bucci, W. 94 Bucci’s model 94 Burns, D. 155 Campbell, W. 150 card book 170 caretakers, psychoeducational groups for 203–204 Carlson, L. 150 catharsis 63, 233, 235–236 Chalmers, B. 193 Chan, K. 95 chaotic thoughts and feelings, organizing 74–75 Chapman, T. J. 47 children’s group 225–227 cinquains 194–195 Classen, C. 95 clinical issues, as dilemmas 24 cognitive abilities, of adults/older adults 230 cognitive behavior drama 130 cognitive theories 7, 140 cohesion: stage of group development 56–57; as therapeutic factors 63, 234 collage activities: Creative Self 88–89; defined 82; Emotional Self 88; favorite things, activity 83; in group 85–86; group leader’s development for using

Index 249 82–83; home 90; inside/outside 89–90; Inspirational Self 88; just play, activity 84; Physical Self 87; purpose and goals of 86–87; scrapbook and 168; shapes 84–85 commonality, for members of diverse conditions 201 confidentiality and privacy 12–13; in restrictive settings 187; in selection of creative activities 29 conflict: activities to address 239; stage of group development 55–56 consensual validation 179–180 constructive feedback 80–81 continued processing, of experience 23 corrective emotional recapitulation 63, 233 countertransference 48 creative activities 8–10; ableness, consideration of 202; basic group conditions for use 27–28; basic planning 202; benefits for use of 4; consultation 202; defined 3; ethical considerations for 10–14; Expansion and Enhancement Phases 41–43; for families and caretakers 203–204; fundamental principles of 22–23; general guiding assumptions 23–29; for group dilemmas 5–6; guidelines for selecting activities 28–29, 200–204; Implementation Phase 30–40; judicious use of 19; phases of constructive use of 29–43; Reporting Phase 40–41; safety and trust 27; selection of 10, 28–29; see also diverse conditions/ settings; specific activities creed, creation of 134–135 Cropley, T. 150 Cully, J. 127 culturally sensitive group leader strategies 61, 62 cultural sensitivity 11; authority figures 58; expressing emotions 59; family, role of 59–60; meaning attribution 61; source for illness or condition 58–59 current wishes, desires, and needs, clues for 22 dance therapy 9, 124–126 defenses, drawing activities 71–73; barriers and constraints 75–82; components, identifying 72–73; concern(s)

73; group-focused activities 75–82; organizing chaotic thoughts and feelings 74–75; tension, relieving 73–74 defensiveness, reducing 22–23, 30, 87 developmental issues 23, 163–164 dialectical behavioral therapy (DBT) 7, 140, 151 Dieckmann, H. 9 difficult member behaviors, managing 220–223 Dimidjian, W. 10 directness, of group leader 49 distress, coping with 146–147 diverse conditions/settings: choice of activity 190–191; commonalities for members of 201; difficult member behaviors, managing 220–223; evoked emotions 191; guidelines for selection of activities 200–204; happy moments lift spirits 214–217; inclusion 217–220; life transitions 206–214; support groups 206; symptoms and self-management 204–206; ways to use creative activities in 194 diversity sensitivity: authority figures 58; expressing emotions 59; family, role of 59–60; meaning attribution 61; source for illness or condition 58–59 Djikuc, M. 92 Dooley, B. 150 drama/performance activities 9, 129–130 dramatic play 130 drawing activities 67; benefits and advantages for 68; bypass defenses 71–82; express feelings by 69–70; focusing awareness 70–71; guidelines for 68–69; selection of 76; uncontaminated expressions 68 dreams 107–108 effective groups, defined 203–204 Elkholm, J. 67 Ellis, A. 7 embedding 241–242 emotional contagion, fear of 189 emotional expression: difficult feelings 220; encouraging 219–220; restricted or inappropriate 188 emotional intensity, activity for reducing 246 emotional presence 45 emotional venting 31, 63, 233, 236

250 Index emotional vulnerability 18 emotions: evoked 191; expressing 59; intense 23, 228; managing 153–154, 228; see also negative emotions empathy 45, 46–47 encouragement and support, by group leader 50 energy, increasing 127–128 Enhancement Phase 41–42 Epstein, E. M. 95 Esterling, B. 95 ethical considerations: confidentiality and limits 12–13; do no harm 10–12; process for resolution 14; professional responsibility in 13 ethical principles 23 Evans, S. 150 evoked emotion 191 excited mood 210 exercise 9; see also physical exercise existential factors 63, 233–234; conflict 239; fostering emergence of 236–239; human suffering 236–238; resistance 238–239 Expansion Phase 41–42 experiential learning 6–7 Expressive Writing 190; autobiographical 98–100; group expressive 97–98; life events 100 Eye Movement Desensitization Reprocessing (EMDR) 140 fables 163 fairy tales 162–166, 194–195 families: psychoeducational groups for 203–204; role of 59–60 fear of conflict 30 feedback: constructive 80–81; giving and receiving 28 feelings: chaotic thoughts and 74–75; difficult 220; express 69–70; expression of 24, 82; identification of 217; immediate 186; music therapy and 155–156 Fehr, E. 133 Ferrando, S. 150 Findler, M. 150 Fisch, R. 47 flats 174, 175–176 Fletcher, K. 150 folk tales 162 Forsyth, D. 52 free associations, writing 103–104

Garland, S. 150 gender, adults/older adults and 230 general life transition 207 gloomy mood 210 Glueckauf, R. 155 Goleman, D. 150 Graham, D. 127 Griffin, R. 193 group: conditions, creative activities 27, 28; environment, contributions of 6; level challenges/process 47, 238; stages 54; see also stages of group development; specific entries group, as a whole 3, 17, 52; benefits on 32, 34; focus on 24, 53, 149; guidelines for drawing activities 75–77; intervention 41; process commentary 17, 47 group dilemmas 5–6; activity, resistance artist trading card 232; cases and creative activities 242–246; clinical issues as 24; creative activities for 231–232; as defense mechanism 27; difficult group member and 231; emotional intensity, activity for reducing 246 group dynamics 47–48, 52–53; adolescent 227–229; adults and older adults 229–231; children 225–227; constructive use of 241; defined 52; group level concerns 231–232; manualized groups 239–246; therapeutic factors 232–239 group-focused drawing activities: accomplishments 78–80; clarifying wants, needs, desires, and wishes 78–79; constructive feedback 80–81; desired outcomes 81; examples for 77; goal and purpose 86; guidelines for 75–77; introductions 77; planning and selecting 86–87; problem solving and decision-making 82; saying hello, activity 77–78; wishes for group 80–81 group leaders 4–5, 24–25; basic skills and attributes 16–19; communication skills 15; culturally sensitive strategies 61–62; development of 14–16, 28; ethical considerations 10–14; expertise 28; fundamental attributes for 44–46; inner experiencing and clinical judgment 28; inner therapeutic self, developing 52–63; preparation of 14;

Index 251 self-development 15–16; skills and processes 241; strategies 61–62; therapeutic skills of 46–52; for using collage 82–83 group members 25–27; advantages for 2–3; benefits for 2–5; creative activities for group dilemmas 5–6; membership, in experiential learning 7; rationale 3–4 Haglin, D. 150 Hansen, H. 96 happy moments 215–216; identification of feelings, activity for 217; things constituting 214 Hayes, S. 152 Hays, T. 154 Health Insurance Portability and Accountability Act (HIPAA) 193 healthy adult narcissism (HAN) 46 Hodas, G. 154 Hoff, B. 151 Hollon, S. 10 Holmes, D. 95 Holton, C. 9 hope 62, 233, 235 Hopko, D. 127 Horneffer, K. 96 human suffering, activities to addressing 236–238 imagery 9, 138–139; coping with difficult situations or distress 146–147; coping with negative emotions 143–145; group concerns, addressing 149–150; guidelines for 140; haven 140–141; for performances 145–146; self-perception 147–149; tension and anxiety, reducing 141–143 imitative behavior 63, 233 Implementation Phase 30–40; activity introduction in 37–38; activity script introduction in 38; decision-making procedure 31–34; encouraging members 40; formal plan for 36–37; materials and supplies, availability of 35–36; observation of members 38–39; planning process 30–31; process for 37–40; questions for exploring and expansion 34–35; raising questions 39 impulse control 151, 189, 202 inclusion 217, 218–219

informed consent 12 inspiration, new ideas and 179 intense emotions 23, 228 interactive storytelling 130 interpersonal learning 62–63, 233 intrusive thoughts, handling 212–213 Ismailji, T. 95 Johnson, D. 52 Johnson, F. 52 journaling: benefits for 111; building pleasure 113; home contents 113–114; professional training programs using 112; types of 114; uses for 111–112; visual 115–116 Kabat-Zinn, J. 150 Kernberg, O. F. 7 kinesics distractors 182 Kingston, T. 150 Klein, M. 7 Kohut, H. 8, 16, 18, 46 Koopman, C. 95 Kristeller, J. 150 Krusmark, E. 150 Kunik, M. 127 L’Abate, L. 95 Lau, M. 150 Lawlor, E. 150 Lazarus, A. 140 leadership skills 15–17; see also group leaders legends 162 Lenderking, W. 150 Leszcz, M. 17, 26, 47, 180 letters, writing 104–107 Lewin, K. 6, 52 life transition groups: being mindful activity 211–212; categories for 206–207; drawing instructions 208; focus on current mood, activity for 210; general life 207; intrusive thoughts, handling 212–213; mood trigger(s), activity for 209; pleasant sights activity 210–211; purposes and goals of 206–207; sample activity 207–208; skin distractors activity 211; special place activity 213–214; specific life 207; writing instructions 208–209 Light, T. 150 listening skills, of group leader 49

252 Index lists power of 108–109 Lopez, A. 193 Lumley, M. 112 Lustgarten, S. 193 Lutgendorf, S. 112 Luxton, D. 193 Macklem, D. 112 Mahler, M. 7, 146 Malone, K. 150 manualized groups: advantages for 239–241; emotional intensity, reducing 246; enhancing with creative activities 241–242; group dilemmas cases and creative activities 242–246 Marra, T. 141 Marx, B. P. 95 Massion, A. 150 McFarlane, W. 203 meanings: attribution of 60; for the product 22 media access 188 Meichenbaum, D. 7 memory activities 9; see also scrapbooks metaphors 51–52 mind-body connection: activity for 120–121; rationale for 119–120 mindfulness 9, 150–151; activity 151–152, 211–212; managing emotions 153–154; passing thoughts 152–153 Minichiello, V. 154 monopolizing 221 Moreno, J. L. 130 movement 8–9, 123–124, 191; see also physical movement Multi-Family Psychoeducational Psychotherapy (MF-PEP) 200 multimodal therapy 140 multiple group sessions 184–186 Murray, E. 95 music therapy 9, 154–156, 190 myths 162–163 narcissistic wounding 8, 17–18 narradrama 130 negative emotions 143–144 new ideas, generating 178–180 nonverbal behavior 53 Nowicka-Sauer, K. 67 Oatley, K. 92 object-relations theories (OR) 7–8

Ohnmeiss, D. 67 older adults groups 229–231; see also adults groups olfactory/smell distractors 182 Palesh, O. 95 past reflections, writing 101–103 Pedersen, E. 164 Pennebaker, J. W. 95, 112 performances 145–146 personal experiencing: of group leader 49; member’s 22 Peterson, L. 150 photography 9, 166–167; see also scrapbooks physical exercise 126–129 physical movement: dance 124–126; general guidelines 121–123; goal or purpose for 122; mind-body connection 119–121; movement 123–124; performance activities 129–130; physical exercise 126–129; role play 130–135 Pine, F. 7 Pizarro, J. 112 pleased mood 210 poems 194–195 Principle of P’u 151 Principle of Wu Wei 151 privacy and confidentiality 12–13; in restrictive settings 187; in selection of creative activities 29 process: commentary 47–48; for resolution 14 professional preparation 11 professional responsibility 13 Prouix, K. 150 Pruitt, L. 193 psychodrama 130 psychoeducational groups 184–186 psychological boundary strength 45 questioning, appropriate 51 Quittner, A. 155 Rastegas, A. 96 Rational Emotive Behavioral Therapy (REBT) 184 Reaser, E. 193 redirecting, group leader and 49–50 reflective of inner world of person 22 reframing, group leader and 49–50 Reich, W. 17–18

Index 253 Reisman, A. 96 relating attributes 14 Reporting Phase 40–41 resistance 53; artist trading card 232; drawing activities and 79; as existential factor 238–239; group 31; group members’ reactions 25; reason for 37, 39 restrictive settings 186–189 Ridgeway, V. 150 Robinson, M. 94 Rogers, C. 14 Rogge, R. 150 role play 9, 130–135 Rosenblad, S. 193 Rothberg, B. 193 Runberg, M. 164 Rutan, J. S. 5, 231 Saltzman, A. 150 scapegoating 222–223 Scharf, M. 150 Schwenk, S. 193 scrapbooks 9, 166, 167–170 Segal, Z. 150 selection guidelines, of creative activities 28–29 self-affirmations 109, 110–111 self-distraction 143 self-exploration 231–232 self-management of symptoms 204–206 self-perception 147–149 self-psychology 8 Selvini-Palazzoli, A. 47 sensory distractors 181–182 session writing: dreams 107–108; free associations 103–104; letters 104–107; lists 108–109; past reflections 101–103; self-affirmations 109–111; single 100–101; see also writing activities Silverman, M. 154 similarities, activity for focus on 227, 234–235 simulations and games 133 Singer, T. 133 single session groups 177; benefits for 178–180; constraints for 180; sample 180–184 Skillings, A. 150 skin distractors, activity for 211 Sloan, D. M. 95

Smart, C. 150 Smothermon, J. 193 socializing techniques 63, 234 Souchek, J. 127 Soulsby, J. 150 specific life transitions 207 Spierings, J. 58, 62 stages of group development 28, 53–57 Stanley, M. 127 Stolorow, R. 46 stories 9, 194–195; choice of 190; creative activities for 165–166; discussing, writing, and drawing 165–166, 194–195; forms for 162–163; read, draw, and write approach 165–166; and unconscious 161–162; see also fables; fairy tales; folk tales; legends; myths storytelling: difficult member behaviors 221–222; interactive 130 Stowell, C. 150 Strosahl, K. 152 support groups 206 Sweig, T. 112 Swenson, J. 193 symptom relief 204–206 tactile/touch distractors 182 taste distraction 144, 182 Teasdale, J. 150 tension: activity for 142–143; reducing 141; relieving 73–74, 78 termination stage, of group development 57 themes and symbols, of fairy tales 164 therapeutic factors 62–63, 232–233, 234; cultural and diversity sensitivity 58–61; existential factors 63, 233–234, 236–239; fostering 228, 234–236; group dynamics 52–53; stages of group development 53–57 therapeutic relationship 11, 28 therapeutic skills, group leaders 44; empathic failures 46–47; empathic responding 46; process commentary 47–48; therapeutic responding/ communication competencies 48–52; transference and countertransference 48 Tojek, T. 112 tolerance and being nonjudgmental 45 touch sensation, positive 144–145 transference, and countertransference 48

254 Index traumas, past 230 Trotzer, J. 51 Trust game 133 Tuckman, B. 54 Ullrich, P. 112 Ungerea, T. 174 universality: fostering emergence of 234; as therapeutic factors 62, 233 Vanharanta, H. 67 Veazey, C. 127 Verghese, A. 96 video interpretation 130 virtual settings 191–194 visual distraction 143–144, 181 visual journaling 9, 115–116, 170–173

Wagner, A. 193 Wales, T. 95 Watzlawick, P. 47 Weakland, J. H. 47 Wheeler, E. 150 Williams, J. 150 Wilson, K. 152 writing activities 8; benefits from 92–94; choice of 190; defined 92; dreams 107–108; Expressive Writing 95–100; free associations 103–104; journaling 111–116; letters 104–107; process and reasons for 94–95; past reflections 101–103; single session 100–101 Yalom, I. 17, 26, 47, 62, 180, 233, 236